V  COLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STANDARD 


8   SURGICAL  ANATOMY  OF  THE  MOUTH 

Atresias  are  caused  by  excessive  union  beyond  the  normal 
and  as  a  result  we  get  partial  or  complete  closure  of  the 
facial  orifices. 


Fig.  6. — Diagram  of  Congenital  Facial  Clefts.  Shaded  portions  indicate 
the  location  of  the  different  congenital  fissures.  HL,  harelip;  IM,  in- 
ferior maxillary  process;  LN,*,  lateral  nasal  process  of  frontal  plate; 
LN,  lateral  nasal  cleft;  MN,  middle  nasal  process  of  frontal  plate; 
OF,  oblique  facial  cleft;  SM,  superior  maxillary  process;  TF,  transverse 
facial  cleft;  *,  lower  part  of  lateral  nasal  process  which  takes  part  in 
the  formation  of  the  upper  lip,  but  not  of  its  red  border;  the  free  red 
margin  of  the  lip  is  formed  by  the  union  of  the  lower  part  of  the  middle 
nasal  process  (MN)  and  the  lower  part  of  the  superior  maxillary  process 
(SM).     (McGrath.) 

The  failure  of  the  embryonal  processes  to  coalesce  and 
the  resulting  clefts  is  due  to  deficient  development  of  the 
processes  themselves. 


Congenital  Deformities 

Congenital  deformities  of  the  face  may  be  divided  into 
two  groups : 

(a)  Those  in  which  the  frontal  plate  or  process  is  con- 
cerned. Under  this  heading  we  have — 1.  Lateral  clefts 
of  the  upper  lip  and  the  alveolar  process;  clefts  of  the 
palate  may  also  be  included  in  this  group;  2.  Median 
clefts  or  notches  of  the  upper  lip  and  deformities  of  the 


THE  DEFORMITIES  OF  THE  FACE  9 

nose;  3.  Notching  of  the  wing  of  the  nose;  4.  Oblique 
facial  clefts. 

(b)  Those  in  which  the  first  visceral  arch  is  involved. 
In  this  group  we  have — 1.  Transverse  facial  fissures ;  2. 
Median  fissures  of  the  lower  lip,  lower  jaw  and  tongue; 
:>.  Deformities  of  the  lower  jaw. 

Deformities  in  which  the  Frontal  Plate  is  Concerned 

These  are  lateral  clefts  of  the  upper  lip  and  of  the 
alveolar  process  and  cleft  palate.  Clefts  of  the  upper  lip 
and  alveolar  process  depend  upon  the  imperfect  union 
of  the  mid-nasal  process  with  the  superior  maxillary  proc- 
esses and  to  failure  of  the  maxillary  bone  and  its  accom- 
panying soft  parts  to  unite  with  the  adjoining  portion 
of  the  face.  These  clefts  are  always  lateral  and  may  be 
present  on  one  or  both  sides.  Clefts  of  the  palate  de- 
pend on  non-union  of  the  palatal  process  of  the  superior 
maxillary  process  of  either  side.  When  both  processes 
are  at  fault  the  cleft  is  median.  If  one  palatal  process 
only  is  involved  the  cleft  is  on  the  corresponding  side 
of  the  median  line,  the  opposite  palatal  process  in  this 
case  being  joined  to  the  lower  border  of  the  vomer. 

If  union  has  failed  on  both  sides  between  the  mid-nasal 
process  and  the  corresponding  part  of  the  superior  max- 
illary process  of  either  side  and  between  the  palatal  proc- 
esses of  the  superior  maxillary  processes  we  have  the 
most  extreme  variety  of  deformities.  There  are  found 
all  degrees  of  this  variety  from  a  complete  cleft  down 
to  a  notching  of  the  upper  lip,  or  a  bifurcation  of  the 
uvula. 

Harelip.— This  condition  may  be  complete  or  incom- 
plete. Incomplete  harelip  consists  in  a  vertical  notch 
in  the  free  margin  of  the  upper  lip.  It  is  located  to  one 
side  of  the  median  line  between  the  middle  and  lateral 
segments  of  the  lip.  It  varies  from  a  slight  notch  to  a 
fissure  which  may  extend  through  the  entire  thickness  of 


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ARMY  DENTISTRY 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 
Columbia  University  Libraries 


http://www.archive.org/details/armydentistryforOOkeye 


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ARMY    DENTISTRY 


FORSYTH    LECTURES   FOR    THE 
ARMY  DENTAL  RESERVE  CORPS 


EDITED 
BY 

FREDERICK  A   KEYES,  D.M.D. 

FORMER  VISITING  DENTIST,  ST.  VINCENt's  ORPHANAGE.   BOSTON 

CONSULTING  DENTIST,  MEDFIELD  STATE  HOSPITAL,  MEDFIELD,  MASS. 

LIBRARIAN  AND  CURATOR  OF  THE  MUSEUM,  FORSYTH  DENTAL  INFIRMARY,  BOSTON 


D.  APPLETON  AND  COMPANY 

NEW  YORK  LONDON 

1918 


2-7-£  "2.372- 

Copyright,  1918,  by 
)D    APPLETON  AND   COMPANY 


Printed  in  the  United  States  of  America 


DEDICATED  TO 

THOMAS  ALEXANDER  FORSYTH,  LL.D. 

FOUNDER  OF  THE 
FORSYTH  DENTAL  INFIRMARY 


FOREWORD 

The  Forsyth  Dental  Infirmary,  the  first  infirmary  of 
its  kind,  dedicated  to  the  children  of  the  world  by  John 
Hamilton  and  Thomas  Alexander  Forsyth  in  memory  of 
their  brothers,  James  Bennett  and  George  Henry  For- 
syth, was  incorporated  in  1910  by  a  Special  Act  of  the 
Massachusetts  Legislature.  The  objects  of  the  institu- 
tion have  been  summarized  as  follows:  (a)  to  educate 
patents,  teachers,  nurses,  and  children  in  the  hygienic 
value  of  healthy  mouths  and  sound  teeth,  and  to  furnish 
instruction  as  to  the  best  methods  of  securing  the  same ; 
(b)  to  prevent  dental  caries  by  oral  prophylaxis  and  by 
the  care  and  preservation  of  the  temporary  teeth;  (c)  to 
investigate  the  causes  and  to  study  the  prevention  of  oral 
diseases  and  caries  of  the  teeth;  (d)  to  remedy,  so  far  as 
possible,  existing  conditions  of  dental  caries  and  other 
oral  diseases;  (e)  to  establish  and  promulgate  a  higher 
standard  of  dental  asepsis ;  (/)  to  furnish  for  the  dental 
profession  an  opportunity  for  charitable  work  and  for 
the  educative  experience  of  a  large  clinic. 

The  Institution  consists  of  many  different  depart- 
ments, such  as  surgical,  extracting,  orthodontia,  Roent- 
gen-ray, research,  oral  hygiene,  library  and  museum, 
clinical,  etc.,  embodying  a  breadth  of  professional  vision 
unsurpassed  in  the  world.  It  is  ideal  for  children,  den- 
tists, and  soldiers.  In  fact,  the  Forsyth  Infirmary,  on 
account  of  its  modern  equipment  and  excellent  staff,  has 
been  accepted  by  the  War  Department  as  a  Base  Hos- 
pital for  the  care  of  jaw  wounds  in  soldiers  returning 
from  the  present  world's  war. 

In  view  of  the  spirit  which  moved  the  founders  to 


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FOREWORD  ix 

erect  this  Institution  for  such  worthy  aims,  it  was  not 
strange  that  the  Forsyth  Institute  should  realize  its  wider 
possibilities  for  good  when  the  nation  mobilized  its  youth 
for  war.  At  the  time  when  war  was  imminent  with 
Mexico  and  the  Massachusetts  militia  was  called  to  the 
colors,  in  compliance  with  the  request  of  the  Mayor  of 
Boston  arrangements  were  perfected  for  a  free  dental 
service  to  all  members  of  the  Ninth  Regiment,  Mass.N.G., 
during  Saturday  and  Sunday,  June  24th  and  25th.  The 
members  of  the  Visiting  Staff  were  called  in  addition  to 
those  of  the  regular  staff,  and  the  entire  65  chairs  in  the 
Infirmary  were  in  constant  use  throughout  the  two  days. 
During  this  time  2,632  operations  were  performed. 

This  patriotic  service  brought  forth  words  of  highest 
praise  from  the  military  heads  of  Massachusetts.  Many 
men  who  would  otherwise  be  unfit  for  military  service 
were  treated  and  made  efficient  soldiers  by  the  proper 
attention  to  their  mouths. 

With  a  similar  end  in  view  the  Institution  conducted  a 
course  in  Army  Dentistry  for  the  benefit  of  those  dentists 
who  might  desire  to  enter  the  service  of  the  government 
in  its  present  crisis.  The  greater  number  of  the  chapters 
in  this  book  are  taken  from  the  lectures  then  given  at  the 
Forsyth  Dental  Infirmary.  They  adhere  as  closely  as 
possible  to  the  following  course,  which  has  been  author- 
ized by  the  Surgeon  General  of  the  Army  and  Navy. 


PREPAREDNESS  LEAGUE 

Exhibit  "A" 

The  following  course  of  instruction  is  suggested  for 
the  preparation  of  candidates  to  enable  them  to  meet  the 
examination  requirements  for  admission  to  the  Dental 
Reserve  Corps  of  the  Army  and  Navy  in  conformity  with 
Dental  Section  from  Synopsis  of  General  Order  No.  32, 
1916,  Officers'  Reserve  Corps. 


FOREWORD  xi 

Dental  Section.     All  Gkades 

Outline  of  Subjects 

1.  Administration.— Army  regulations,  so  far  as  they 
relate  to  the  dentist  as  an  officer  of  the  army. 

Manual  for  the  medical  department  so  far  as  it  relates 
to  the  duties  of  the  dental  corps. 


Director  Cross 
of  Forsyth 


Major  Jones,  U.  S.  A.,  Dr.  Johnson, 

Contributor  Trustee  of  Forsyth 


(Blanks  should  be  furnished  and  applicants  required  to 
exemplify  their  use  in  the  preparation  of  reports  and 
returns.) 

2.  Technical  Professional  Subjects. — These  are  pre- 
scribed by  the  Surgeon  General,  as  follows: 

Asepsis  and  antisepsis  in  relation  to  wounds  involving 
the  mouth  and  jaws. 

Oral  hygiene  in  relation  to  wound  infection. 


Nose  and  Throat  Operating  Room. 


Amphitheater. 


FOREWORD  xiii 

Anesthesia. —  (a)  review  of  the  pharmacology  and 
teclmic  of  administration  of  ether,  chloroform,  nitrous 
oxid,  nitrous  oxid  and  oxygen,  etc.,  when  used  as  general 
anesthetic  agents;  (b)  review  of  the  pharmacology  and 
teclmic  of  administration  of  cocain,  novocain  and  their 
coproducts  for  the  induction  of  local  anesthesia. 

Dental  and  oral  prosthesis. —  (a)  as  related  to  the  loss 
of  the  hard  and  soft  tissues  resulting  from  wounds  in- 
volving the  mouth  and  jaws;  (/>)  the  mechanical  treat- 
ment of  fractures  of  the  jaws  by  wiring  and  splinting, 
and  the  teclmic  of  splint  construction;  (c)  the  dental 
preparation  for  subsequent  operations  by  the  surgical 
staff. 

Dental  and  oral  practice  in  the  army  and  navy. —  (a) 
in  relation  to  the  service;  (b)  in  relation  to  the  Admin- 
istration and  Supply  Department;  (c)  in  relation  to  other 
military  duties  of  dental  surgeons. 

3.  Military  Law. — Manual  for  Courts-Martial  (official). 

Note.  Lectures  under  Section  1 — Dental  and  Oral 
Practice  in  the  Army;  of  Section  2  and  Section  3 — Mil- 
itary Law,  to  be  given  by  an  Army  Dental  Surgeon;  the 
time  occupied  for  this  part  of  the  course  to  involve  not 
less  than  two,  nor  more  than  ten,  days  of  the  course. 

Approved  by 

Robert  E.  Noble, 

Major  M.  C,  U.  S.  A., 

for  the  Surgeon  General. 
Heartily  approved, 

W.  S.  Braisted, 
Surgeon  General,  U.  S.  N. 


XIV 


FOREWORD 


FORSYTH  LECTURE  COURSE 

These  lectures  were  attended  by  over  600  practicing 
dentists.  The  course  was  very  intensive,  lasting  for  six 
consecutive  days  from  9  a.  m.  to  7  p.  m.,  and  including 
lectures,  clinics,  etc. 

Before  taking  the  course  each  man  was  informed  that 
at  its  completion  he  was  expected  to  take  his  examina- 


First  Class  of  Dentists  Attending  Lectures  for  the    U.  S.  A. 


tion  for  the  United  States  Army  immediately  and  be 
ready  for  duty  in  France  at  once.  Not  one  applicant 
refused  to  take  the  course.  In  fact,  at  the  present  time 
all  the  resources  of  the  examining  board  have  been 
strained  to  the  breaking  point  in  examining  dentists 
eager  to  qualify  as  army  dental  surgeons. 

It  is  hoped  that  the  compilation  of  these  lectures  in., 
book  form  will  aid  many  dentists  throughout  the  country 


Militiamen  on  Steps  at  Forsyth  Waiting  for  Dental  Services 


Militiamen    Being    Treated   by   Forsyth    Staff. 


Militiaman   Receiving  Dental  Treatment. 


Trustees  of  Forsyth  Dental  infirmary. 

Left  to  Right,  Standing:  Dr.  Ernest  A.  Johnson,  Dr.  Harold  Williams,  Dr.  .John  F. 
Dowsley,  Dr.  Gurdon  Mackav,  Mr.  Nelson  Curtis,  Dr.  Harold  DeWitt  Cross,  Dr.  Timothy 
Leary.  Left  to  Right,  Sated:  Mr.  Edward  Hamlin,  Mr.  Thomas  Alexander  Forsyth,  Pres- 
nl   nt.   Mr.  Chester  B.  Humphrey. 

xvi 


FOREWORD  xvii 

who  were  unable  to  profit  by  these  lectures,  to  prepare 
for  the  Army  Dental  Corps. 

It  should  be  remembered  that  the  book  is  not  intended 
as  a  complete  text-book  but  rather  a  compendium  of 
dental  information  for  review  purposes. 

We  prophesy  that  our  dentists  serving  in  the  army 
for  their  country  and  homes  will  make  an  enviable  repu- 
tation and  place  dentistry  in  a  secure  position  as  one  of 
the  noblest  and  most  worthy  professions.  As  Americans 
and  dentists  we  live  to  serve  our  country  and  our  profes- 
sion. If  this  book,  which  is  a  pioneer  in  the  field  of  mili- 
tary dentistry,  shall  enable  anyone  who  reads  it  to  ren- 
der more  efficient  service,  it  will  have  served  its  purpose 
and  justified  its  existence. 

The  editor  wishes  here  to  acknowledge  his  indebted- 
ness to  the  various  contributors  and  to  the  Director  and 
Trustees  of  the  Forsyth  Dental  Infirmary,  without  whose 
help  and  encouragement  the  work  would  not  have  been 
possible. 

Frederick  A.  Keyes,  D.M.D. 
416    Marlborough    Street, 

Boston,  Mass. 
December,  1917. 


LIST  OF  COLLABORATORS 

HARRY  H.  GERMAIN,  M.D. 
Former  Professor  of  Anatomy,  Tufts  Medical  School. 

GEORGE  VAX  NESS  DEARBORN,  Ph.D. 

Instructor    in    Psychology    and    Education,    Sargent    Normal    School; 

Physiologist  and  Psychologist  to  the  Forsyth  Dental 

Infirmary  for  Children. 

PERCY  R.  HOWE,  D.M.D. 
Member  Research   Department,  Forsyth  Dental  Infirmary. 

FRANK  G.  WHEATLEY,  A.M.,  M.D. 
Professor  of  Materia  Medica  and  Therapeutics,  Tufts  Medical  School. 

WILLIAM  E.  PREBLE,  M.D. 
Assistant  Visiting  Physician,  Boston  Dispensaiy  Medical  Department. 

HAROLD  DeWITT  CROSS,  D.M.D. 

Former  Assistant   Professor  of  Prosthetic  Dentistry,  Harvard  Dental 

School;  Director  Forsyth  Dental  Infirmary. 

ALBERT  L.  MIDGLEY,  D.M.D. 
Lecturer  on  Dentistry,  Harvard  University  Dental   School;   Oral   Sur- 
geon, Forsyth  Dental  Infirmary;  Lecturer  on   Surgery,  Forsyth 
Ti'aining  School,  Boston;  Dental  Surgeon,  Rhode  Island 
Hospital;  Dental  Surgeon,  St.  Joseph's  Hospital; 
Oral  Sm'geon,  John  W.  Keefe  Surgery;  Con- 
sulting!' Dental  Surgeon,  St.  Vincent's 
Infant  Asylum,  Providence. 

BYRON  HOWARD  STROUT,  D.D.S. 
Instructor  Tufts  Dental  School. 

WILLIAM  A.  GOBIE,  D.M.D. 
Resident  Exodontist,  Forsyth  Dental  Infirmary. 

JAMES  J.  HEPBURN,  M.D. 
Visiting  Surgeon,  Boston  City  Hospital. 

FREEMAN'  ALLEN,  M.D. 

Consulting  Anesthetist,  Massachusetts  General  Hospital,  Children; 

and  Free  Hospital  for  Women. 

xix 


xx  LIST  OF  COLLABORATORS 

FREDERICK  W.  O'BRIEN. 

Assislaul    Professor    Roentgenology,    Tufts    Medical    School;    Visiting 

Roentgenologisi   to  the  Cambridge  Bospital,  All.  Auburn  Si., 

and  Boston  Consumptives'  Hospital;  Member  of  the 

American  Roentgen  Ray  Society. 

WILLIAM  E.  CHENERY,  A.B.,  M.D. 

Professor  Laryngology,   Tufts  Medical    School;   Laryngologist  to   the 

Boston  Dispensary,  St.  Elizabeth's  Hospital  and  (lie 

Forsyth  Dental  Infirmary. 

HOWARD  H.  SMITH,  M.D. 
Professor  of  Materia  Medica,  Massachusetts  College  of  Pharmacy. 

HARRY  SHUMAN,  D.M.D. 

Former  Instructor  and  Lecturer  in  Oral  Surgery,  Harvard  Dental 

School;  Visiting  Oral  Surgeon,  Forsyth  Dental  Infirmary. 

MAJOR  FREDERICK  L.  JONES,  U.  S.  A. 

Editor  FREDERICK  A.  KEYES,  D.M.D. 

Past   Visiting  Dentist,    St.   Vincent's   Orphanage,   Boston;    Consulting 

Dentist,  Medfield  State  Hospital;  Librarian  and  Curator  of 

Museum,  Forsyth  Dental  Infirmary,  Boston. 


CONTENTS 

CHAPTER  PAGE 

I.     Surgical  Anatomy  of  the  Mouth       ....  1 

II.    Recent  Advances  in  Physiology 85 

III.  Dental    Pathology    axd    Bacteriology,    Chemistry, 

Physics   and   Metallurgy 103 

IV.  Pharmacology 118 

V.     Pre-operatiye    and    Postoperative    Medical    Care   of 

Patients 150 

VI.     Maxillary  Fractures   (Medical  Treatment)       .        .  165 

VII.     Maxillary  Fractures   (Surgical  Treatment)      .         .  196 

VIII.     Extraction  of  Teeth 238 

IX.     Novocain  Technic .274 

X.     Surgical  Technic  and  Bandaging 286 

XI.     General  Anesthesia,  its  Pharmacology  and  Admin- 
istration   209 

XII.     Military  Roentgenology   for  Dentists       .        .        .  310 

XIII.  Venereal     Diseases     (Syphilis)     and     Diseases     of 

Mouth  and  Nose 33S 

XIV.  Appearances  of  the  Mouth  in  Some  of  the  Common 

Infectious    Diseases 376 

XV.     Recent  Advances  in  Dental  Surgery  and  Technic    .  392 

XVI.     Military  Administration 401 

XVII.     Military  Dental  Laws 453 


xxi 


LIST  OF  ILLUSTRATIONS 

FIGURE  pAGE 

1. — Transverse  Section  of  the  Head  End  of  an  Embryo  Twelve 

Days   Old 2 

2. — Sagittal  Section  of  the  Head  End  of  an  Embryo  Twelve 

Days   Old 2 

3. — Embryo  about  Fourth  Week,  Seen  from  Side     ...  3 

4.— Face  of   Embryo,   Fifth   Week 4 

5. — Embryo   about    Eighth   Week 5 

6. — Diagram  of  Congenital  Facial  Clefts 8 

7. — Double  Complete  Harelip 10 

8. — Harelip  with  Advanced  Intermaxillary  Portion  ...  10 
9. — Double  Cleft  Palate  with  Advanced  Intermaxillary  Portion 

Carrying  the  Sockets  of  Two  Incisor  Teeth  ...  10 

10.— Incomplete  Oblique  Facial  Cleft 13 

11.— Transverse    Facial    Cleft 14 

12. — Antrum  of  Highmore 25 

13. — Antrum  of  Highmore   and   Surface  Location  2G 
14. — Showing  the  Incomplete  Fusion  of  the  Palatal  Plates  and 
the   V-shaped  Interval   Filled  by  the   Intermaxillary 

Bone 2S 

15. — Bone  of  the  Lower  Jaw       .......  31 

16. — Bone  of  the  Lower  Jaw       .......  31 

17. — Bone  of  the  Lower  Jaw       .......  31 

18. — a,    Supra-orbital   Foramen;   b,    Infra-orbital    Foramen;    c, 

Mental    Foramen 34 

19. — Line  of  Supra-orbital,  Infra-orbital,  and  Mental  Foramina  34 

20. — Masseter  Muscle 43 

21. — Temporal  Muscle 44 

22. — Pterygoid   Muscles 45 

23. — Branches  of  the  Facial  Nerve  Spread  Over  the  Face  Like 

a  Fan 61 

24.— Surface  Markings  of  the  Face 62 

25. — The  Laryngeal  Nerves  ........  65 

26. — Vertical   Section  of  Mouth  and  Pharynx     ....  67 

27.— Palate  and  Alveolar  Arch 68 

28.— The  Under  Surface  of  the  Tongue 69 

29.— The  Tongue .69 

30. — Areas  of  Nerve  Distribution  on  the  Surface  of  the  Tongue  70 
31. — The  Primary  Cervical  Triangles  Formed  by  the  Sternomas- 

toid  Muscle 79 

32.— Triangles  of  the  Neck 79 

33. — The  Outer  Region  of  the  Neck  Showing  the  Occipital  and 

Supraclavicular    Triangle       .         .         .         .         .         .80 

34. — Surface  Markings  of  the  Anterior  Part  of  the  Neck    .         .  81 

xxiii 


xxiv  LIST  OF  ILLUSTRATIONS 

FIGURE 

.'55. — The  Carotid   Region  and  the  Chief  Structures 
:{().— The  Chief  Arteries  of  the  Neck  . 
.'57. — Hemobarogram,  A   22  . 

38.— Hemobarogram,  I?1  IS 

39. — Hemobarogram,  A  14    . 

10. — Hemobarogram,  D2  3    . 

41. — Microorganisms  from   Dental   Caries,   15 

42.— Effect  of  Abscessed  Condition  on  Tooth  Structure 

43. — Teeth  after  Treatment  with   Metallic   Silver  Impregnation 

44. — Chopart's   Appliance     ...... 

-1"). — Bone  Wiring:    Modified  Form     .... 

46. — Ligature  Method:    Hammond  Modification  . 

47. — Ligature  Method:    Merged    Clamps 

48. — Metal  Splint  Devised  by  Moon     .... 

49.— Modified  Metal  Splint  ...... 

50.— Modified  Metal   Splint 

51. — Hayward   Splint    ....... 

52. — Bullock's  Modification  of  Hayward  Splint    . 

53. — Kingsley  Splint     ....... 

54. — Interdental  Splint  ...... 

55. — Interdental  Splint  Used  in  Confederate  Army     . 
56. — Interdental   Splint    (Allen)    ..... 

57.— Modified  Moon  Splint 

58. — Crib    Splint    (Kingsley) 

59. — Multiple  Fracture  ....... 

60. — Separated   Double   Fragment        .... 

61. — Deformity  after  Necrosis      ..... 

62. — Ununited  Gunshot  Injury 

63.— Split  Jacket  Plate  with  Jack-Sciw     . 

64. — Triple   Fracture 

65. — Vulcanite  Plate  with  Arms  ..... 

66. — Fractured  Fragment  with  Four  Teeth  . 

67. — Models  of  Displacements  and  Splints  Used  for  Fixat 

68. — Plaster  Model,  Cut  at  Line  of  Fracture 

69. — Hard  Plaster  Model,  Impression  .... 

70. — Model  Set  on  Anatomical  Articulator  . 

71. — Upper  Model  Attached  to  Articulator  . 

72. — Simple  Vulcanite  Jacket  Splint  .... 

73. — Vulcanite  Splint  with  Arms  for  Bandaging  . 

74.— Fitted  Metal   Splint       .         .         .         . 

75. — Interdental    Vulcanite    Splint         .... 

76. — Angle    Orthodontia   Band      .  ... 

77. — No.   2   Angle   Apparatus 

78. — Figure  of  Eight   Ligature 

79. — Ligatures  Properly  Adjusted        .... 

80. — Wiring  of  Fracture  with  Tendency  to  Displacement 
81. — Four-Tailed   Bandage  .  ... 

82. — Barton   Bandage  ...  .... 

83. — Fracture  Between  Lower  Right  Cuspid  and  First  Bicuspid 

84. — Fracture  at  the  Neck  of  the  Condyle  and  in  the  Body  of  the 

Mandible         ......... 

85. — Study    of   Displacement 


PAGE 

82 
83 
99 

loo 
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117 
Kit! 
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ins 
L69 
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1S3 
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FIGURE 

86.— 

87  — 
88.— 
SO  — 


90.- 
91.- 

92.- 
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95.— 

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113.- 

114, 

115.- 

116, 


117, 
118, 
119. 
120. 
121. 
122. 
123. 


LIST  OF  ILLUSTRATIONS 

Fracture  Anterior  to  Angle  with  Characteristic  Little  Dis- 
placement      ......... 

Front  and  Lateral  Views  of  Skull  Cap  in  Position 

Fracture  at  the  Neck  of  the  Condyle 

Showing  Bands,  Bar  and  Intermaxillary  Elastics  in  Treat- 
ment of  a  Case  in  Which  Both  Condyle  and  Body  of  the 
Mandible  Have  Been  Fractured     .... 

Extensive  Necrosis         ....... 

Extensive  Necrosis.  Same  as  Figure  90.  (Six  months 
later)       

Pathological  Fracture    ....... 

Unerupted   Malposed   Third   Molar       .... 

Fracture  Between  the  Right  Inferior  Second  Bicuspid  and 
First   Molar  . 

Fracture  of  the  Body  of  the  Bone  Between  First  and  Third 
Inferior  Molars  with  the  Second  Molar  Missing  . 

Fracture  of  the  Body  of  the  Bone  with  Considerable  Dis- 
placement and  No  Tooth  in  the  Distal  Fragment   . 

Position  for  Upper  Extraction      ..... 

Position  for  Lower  Extraction      ..... 

Palm  View,  Handgrasp,  Upper  Forceps 

Dorsal  View,  Handgrasp,  Upper  Forceps    . 

Handgrasp,  Lower  Forceps  ...... 

A  Modern  Equipped  Table  for  Novocain  Anesthesia  . 

Showing  Direction  of  Needle  in  Mandibular  Injection  . 

Showing  Direction  of  Needle  and  Position  of  Syringe  and 
Hands  in  Mandibular  Injection    .... 

Showing  Direction  of  Needle  in  Zygomatic  Injection  . 

Position  of  Hands  and  Syringe  in  Zygomatic  Injection 

Showing  Direction  of  Needle  in  Infra-orbital  Injection 

■Showing  Direction  of  Needle  and  Position  of  Hands  in 
Infra-orbital  Injection  ....... 

■Showing  Direction  of  Needle  in  Mental  Foramen  Injection 

Showing  Direction  of  Needle  in  Anterior  Palatine  Injection 

Showing  Direction  of  Needle  in  Posterior  Palatine  Injection 

■Author's  Instruments  Brought  Down  to  a  Minimum  Num- 
ber .......... 

-Proper  Position  of  Operator,  Hands  and  Forceps  in  Using 
Lower  Molar   English   Forceps     .         .         .         .         . 

-Proper  Technic  in  Lower  Root  Extraction  with  Special 
Elevator  ......... 

-Proper  Position  of  Hands  and  Forceps  in  Extracting  Up- 
per Right  Molar   ........ 

-Showing  Proper  Method  of  Using  Elevator  and  the  Position 
of  the  Left  Hand  to  Prevent  Luxation  of  the  Adjoin- 
ing Tooth       ........ 

-Steam    Autoclave    ........ 

-Drains  for  Clean  and    Suppurating  "Wounds 

-Continued   or  Glover's   Suture 

-The  Intracutaneous  or  Subcuticular  Suture  . 

-Interrupted   Suture        ....... 

-Recurrent  Bandage  of  the  Head  ..... 

-Crossed  Figure-of- Eight  Bandage  of  Both  Eyes  . 


XXV 

PAGE 


213 
215 

217 


21S 
219 

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23G 

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27S 

27!) 
2S0 
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281 


2S2 
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2S3 
2S4 


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297 


X  X  V  1 
FIGURE 

L24. 

125.— 

126 

127.— 
12S 
128  a. 

129.— 

130.— 

131. 


LTST  OF  TLLUSTKATTONS 


Barton's  Bandage,  or  Figure-of-Eighl  of  the  Jaw 
The   Pour-Tailed   Bandage    ...... 

Type  of  Gas  Tube  in  Common  Use     .... 

The  Victor  Hydrogen  Tube  ...... 

Coolidge   Tube 

Diagram   Showing  Wiring  Circuit   of  Coolidge  Tube 
The  Sialic  nr  So-Called  Influence  Machine  . 
Induction  Coil  Type  of  Apparatus  for  Producing  X-Rays 
Interior  View  of  Ihterrupterless  Transformer  Type  of  Ap- 
paratus Supplied  the   U.  S.  Government 

132. — Type  of  Roentgenoscopie  Table  Supplied  the  U.  S.  Gov- 
ernment, so  Constructed  That  Injured  Soldier  May  Be 
Examined   from  Head  to  Foot  Without  Being  Moved 

133. — Diagram  Showing  the  Results  of  Correct  and  Incorrect 
Technic  from  McCov,  Internat.  Journal  Orthodontia, 
Vol.    I,   No.   1        .  *      . 

134. — Showing  Normal  Antra  and  Position  Preferred  by  Author 

135. — Wheatstone   Stereoscopic   Illuminator 

136. — Illustrating  Method  of  Introducing  Sutton  Localizing 
Cannula  .... 

137.— Simple   Cysts  .... 

138. — Upper  View  Shows  Probe  Inserted  into  Fistula  at  Second 
Molar 

139. — Follicular  or  Dentigerous  Cyst 

140. — Adamantinoma  or  Multilobular   Cyst    . 

141. — Impacted  Lower  Third  Molar       ..... 

142. — Fracture  of  Ramus  of  Mandible  and   Superior  Maxilla 

143. — Fracture  of  Lower  Jaw  from    Gunshot 

144. — Fracture  of  Lower  Jaw  Near  Symphysis  not  Easily  Dem- 
onstrated in  Lateral  View     ..... 

145. — Objective  Appearance  of  Wounds  Received  in  Warfare 

146. — Objective  Appearance  of  Wounds  Received  in  Warfare 

147. — Treatment   of  Gunshot   Wounds   . 

148.— The  Spirochaeta  Pallida 

149. — Late  Secondary  Lesion  . 

150. — Mucous    Patches     .... 

151. — Gumma  of  Tongue 

152. — Gumma  of  Tongue 

153. — Chancre  of  the  Upper  Lip  (Porter) 

154. — A  Very  Early  Stage  of  the  Secondary 
with  Skin   Eruption 

155. — Saddleback   Nose   .... 

156. — Syphilis  of  Nose    .... 

157.— Syphilitic  Nodes  of  the  Skull      . 

158. — Hereditary  Syphilis 

159. — Hntchinsonian   Teeth 

160. — Geographic  Tongue 

161. — Leukoplakia   ..... 

162. — Carcinoma  of  Tongue    . 

163. — Operation  on  Antrum    . 

164. — Luc    Caldwell    Operation 

165. — Luc    Caldwell    Operation 

166. — Denker  Operation  .... 


Lesion  of  Syphilis 


PAGE 

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320 


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LIST  OF  ILLUSTRATIONS  xxvii 

PAGE 
FIGURE 

167.— Nasal  Polyps 371 

16S  —  Deviated  Septum .•         •  6t" 

169  A,  B,  C,  D. — Stages   of   Teehnic   in   Submucous   Resection   of 

Deviated  Nasal   Septum 373,  374 

170.— Extent  of  Septal  Removal  Necessary  to  Equalize  the  Nos- 
trils and  Promote  Normal  Ventilation  ....  375 
171. — O'Dwyer's  Intubation  Tube 390 


ARMY  DENTISTRY 

CHAPTER  I 

SURGICAL  ANATOMY  OF  THE  MOUTH 

Harry  H„  Germain,  M.  D. 

DEVELOPMENT  OF  THE  FACE 

Oral  Plate.— A  cross  section  of  the  head  of  the  embryo 
about  the  twelfth  day  shows  it  to  consist  of  two  tubes, 
one  in  front  of  the  other.  The  anterior  is  the  blind  end 
of  the  alimentary  canal,  while  the  posterior  is  the  en- 
larged neural  tube  which  later  develops  into  the  brain. 
The  anterior  wall  of  the  head  end  of  the  alimentary  tube 
is  called  the  oral  plate,  which  marks  the  location  of  the 
head  and  face. 

Visceral  Arches.— About  the  third  week  there  appear 
on  either  side  of  the  head  end  of  the  embryo  four  trans- 
verse plates  separated  from  each  other  by  deep  clefts. 
The  plates  are  called  the  visceral  arches;  the  fissures, 
the  visceral  clefts.  The  uppermost  of  these  arches  is 
concerned  in  the  formation  of  the  face  and  unites  in  the 
middle  line  with  its  fellow  of  the  opposite  side  to  form 
the  mandibular  arch  which  represents  the  lower  jaw. 
The  three  lower  arches  do  not  cross  the  middle  line  in 
front,  but  are  continued  into  a  mass  of  tissue  which 
forms  the  front  wall  of  the  pharynx. 

Oral  Pit.— Owing  to  the  growth  of  the  visceral  arches 
and  the  presence  of  the  overhanging  forebrain  the  oral 
plate  becomes  depressed  into  a  fossa  called  the  oral  pit. 

1 


2   SUKUICAL  ANATOMY  OF  THE  MOUTH 

The  oral  pit  represents  the  future  oral  and  nasal  cavities. 

Superior  Maxillary  Process.— On  each  side  of  the  oral 

pit  there  appears  on  the  back  part  of  the  first  visceral 


Fig.  1. — Transverse  Section  of  the  Head  End  of  an  Embryo  Twelve 
Days  Old.  A,  alimentary  tube;  N,  neural  tube;  NC,  note-chord;  OP, 
oral  plate.     (McGrath.) 

arch  of  either  side  a  mass  of  tissue  called  the  superior 
maxillary  process.    Superiorly,  corresponding  to  the  up- 


Fig.  2. — Sagittal  Section  of  the  Head  End  of  an  Embryo  Twelve  Days 
Old.  A,  alimentary  tube;  FB,  vesicle  of  the  forebrain  overriding  the 
end  of  the  alimentary  tube;  N,  neural  tube;  NC,  notochord;  OP,  oral 
plate  (site  of  future  mouth),  winch  ruptures  during  the  fourth  week. 
(McGrath.) 


DEVELOPMENT  OF  THE  FACE  3 

per  part  of  the  oral  pit,  is  a  broad  process  developed  by 
the  downward  growth  of  the  anterior  wall  of  the  vesicle 
of  the  forebrain.  This  grows  downward  and  plays  an 
important  part  in  the  development  of  the  face.  The  oral 
pit  is  now  bounded  above  by  the  frontal  process,  below 
by  the  mandibular  arch,  and  laterally  by  the  superior 
maxillary  process.     The  eyes  lie  on  either  side  of  the 


Fig.  3. — Embryo  About  Fourth  Week,  Seen  from  Side.    1,  2,  3,  4,  visceral 
arches  with  clefts  between  them.      (McGrath.) 

head  between  the  superior  maxillary  process   and  the 
outer  part  of  the  frontal  process. 

Frontal  Process. — The  frontal  process  is  broad  and 
consists  of  a  middle  portion,  the  mid-nasal  process,  and 
two  lateral  portions,  the  Lateral  nasal  processes.  The 
mid-nasal  process  is  broad  and  notched  in  the  middle. 
The  lateral  nasal  processes,  one  on  either  side  of  the 
frontal  process,  are  separated  from  the  mid-nasal  process 
by  a  notch  called  the  olfactory  groove. 


4   SUKGICAL  ANATOMY  OF  THE  MOUTH 

Ultimate  Conformation  of  Face. — Aboul  the  fourth 
week  the  oral  pit  ruptures  and  establishes  a  communi- 
cation from  without  with  the  alimentary  tube. 

About  the  fifth  week  the  appearance  suggests  the  ulti- 
mate conformation  of  the  face.  The  superior  maxillary 
processes  approach  the  median  line,  the  frontal  process 


MN 


Fig.  4. — Face  of  Eaieryo,  Fifth  Week.  Front  view.  IS,  eye;  IM,  inferior 
maxillary  process  (first  visceral  arch)  joins  in  middle  line  with  its  fellow 
of  the  opposite  side  to  form  the  mandibular  arch  (future  lower  jaw) ;  LN, 
lateral  nasal  process  (outer  extremity  of  the  frontal  process)  ;  MN,  mid- 
dle nasal  process  (middle  portion  of  frontal  process)  ;  NN,  nasal  notch 
(future  nostril)  ;  8M,  superior  maxillary  process  (upper  back  part  of  the 
first  visceral  arch)  ;  1,  2,  3,  first,  second,  and  third  visceral  arches. 
(McGrath.) 


is  longer  and  its  separation  into  a  middle  and  lateral 
portion  is  more  pronounced.  The  eyes  are  still  located 
on  the  side  of  the  head. 

About  the  seventh  week  the  superior  maxillary  process 
is  partly  fused  with  the  lateral  nasal  process  of  the 
frontal  plate;  the  line  of  fusion  corresponds  with  the 
position  of  the  tear  duct.  If  union  does  not  occur  along 
this  line  we  have  a  deformity  called  an  oblique  facial 
cleft.     At  this  time  the  eye  is  entirely  surrounded  and 


DEVELOPMENT  OF  THE  FACE  5 

is  placed  more  to  the  front  of  the  face.  The  middle  por- 
tion of  the  frontal  plate  is  still  notched;  the  extremities 
of  the  midnasal  process  have  become  fused  with  the  low- 
est part  of  the  superior  maxillary  process,  forming  the 
upper  lip  and  closing  the  olfactory  grooves  which  are 
converted  into  the  nostrils.  If  the  superior  maxillary 
process  and  the  middle  portion  of  the  frontal  plate  fail 


o* 


Fig.  5. — Embryo  About  Eighth  Week.   Development  of  face  well  advanced. 

(McGrath.) 


to  unite  we  have  as  a  result  a  harelip  which  may  or  may 
not  reach  into  the  nostril. 

The  lower  edge  of  the  superior  maxillary  process  be- 
comes partly  united  with  the  upper  border  of  the  mandib- 
ular process  and  in  this  way  the  size  of  the  mouth  is 
much  diminished.  If  this  union  is  defective  we  have 
a  deformity  known  as  macrostoma.  If  union  is  excessive 
we  may  have  an  extremely  small  mouth  or  microstoma. 
(See  Fig.  4.) 


6   SURGICAL  ANATOMY  OF  THE  MOUTH 

To  summarize:  the  first  visceral  arch  is  eventually 
developed  into  the  inferior  maxillary  bone  and  the  ad- 
joining soft  parts,  including  the  lower  lip  and  the  floor 
of  the  mouth,  and  assists  in  the  formation  of  the  tongue. 
The  superior  maxillary  process  of  the  first  visceral  arch 
is  developed  into  the  superior  maxillary  bone  and  the  ad- 
joining soft  parts.  The  frontal  plate  and  its  lateral  por- 
tion, the  lateral  nasal  process,  form  the  side  of  the  nose, 
including  the  nasal  bones ;  its  middle  portion,  the  middle 
nasal  process,  forms  the  bridge  of  integument  between 
the  nostrils,  reaching  from  the  tip  of  the  nose  to  the  up- 
per lip,  and  the  cartilaginous  and  bony  portions  of  the 
nasal  septum  (vomer  and  perpendicular  plate  of  the 
ethmoid),  also  the  middle  portion  of  the  upper  lip  and 
intermaxillary  bone. 

Intermaxillary  Bone.— The  intermaxillary  bone  is  a 
small,  wedge-shaped,  bonjT  process  which  is  attached  to 
the  anterior  end  of  the  vomer  and  fits  into  a  correspond- 
ing triangular  space  in  the  anterior  part  of  the  hard 
palate,  and  carries  the  four  incisor  teeth.  The  line  of 
union  between  this  bone  and  the  palatal  processes  of  the 
superior  maxillary  may  often  be  plainly  seen  in  the  adult 
upper  jaw-bone.  The  anterior  palatine  canal  marks  the 
junction  of  these  parts.  A  non-united,  abnormally  placed 
intermaxillary  bone  often  complicates  harelip. 

Formation  of  the  Palate.— The  superior  maxillary 
process  of  either  side  gives  off  on  its  median  aspect  a 
shelf-like  plate  of  bone  called  the  palate  process.  These 
processes  grow  toward  the  median  line  and  unite,  form- 
ing the  hard  and  soft  palate.  The  union  usually  takes 
place  from  before  backward,  the  uvula  being  the  last  part 
to  unite.  Union  between  these  processes  is  complete 
about  the  eleventh  week.  With  the  formation  of  the 
hard  and  soft  palates,  the  nasal  cavity  is  separated 
from  the  cavity  of  the  mouth.  Failure  of  union  between 
the  palate  processes  gives  rise  to  the  various  degrees  of 
cleft  palate.    In  front,  where  the  two  halves  of  the  hard 


THE  DEFORMITIES  OF  THE  FACE  7 

palate  join  with  the  intermaxillary  bone,  there  are  a 
suture  line  and  the  anterior  palatine  canal. 

The  vomer  and  the  perpendicular  plate  of  the  ethmoid 
are  developed  from  the  mid-nasal  process  and  divide  the 
nasal  cavity  into  two  parts.  The  junction  between  the 
lower  border  of  the  vomer  and  the  hard  palate  occurs 
after  the  two  palate  processes  have  united  with  each 
other  in  the  mid-line.  The  nasal  cavity  opens  anteriorly 
through  the  nostrils  and  posteriorly  into  the  naso- 
pharynx. 

The  Teeth.— The  margins  of  the  upper  and  lower  jaw 
become  prominent  and  form  the  alveolar  processes ;  the 
epithelium  covering  these  processes  becomes  invaginated, 
dips  down  into  the  substance  of  the  process  and  forms 
the  teeth.  The  floor  of  the  mouth  is  developed  from  the 
first  visceral  arch. 

The  Tongue.  — The  anterior  portion  of  the  tongue  is 
developed  from  the  first  arch,  the  posterior  part  from 
the  second  and  third  arches.  The  anterior  portion  is 
developed  from  the  tubercle  which  appears  in  the  front 
of  the  mouth  near  the  junction  of  the  two  halves  of  the 
first  arch.  The  back  part  is  developed  from  two  tuber- 
cles which  appear  at  the  junction  of  the  second  and  third 
arch.  These  two  parts  of  the  tongue,  the  anterior  and 
the  posterior,  become  joined,  the  line  of  union  being  in- 
dicated by  the  V-shaped  row  of  papillae  upon  the  dor- 
sum of  the  adult  tongue.  At  the  apex  of  the  V  there 
is  a  dimple,  the  foramen  cecum,  which  indicates  the 
point  of  junction  of  the  parts  from  which  the  tongue  is 
formed. 

THE  DEFORMITIES  OF  THE  FACE 

These  consist  of  abnormal  clefts  and  atresias  which 
may  be  partial  or  complete.  Clefts  are  due  to  the  entire 
or  partial  absence  of  normal  union  between  the  original 
embryonal  processes  by  union  of  which  the  face  is  formed. 


8   SURGICAL  ANATOMY  OF  THE  MOUTH 

Atresias  are  caused  by  excessive  union  beyond  the  normal 
and  as  a  result  we  get  partial  or  complete  closure  of  the 
facial  orifices. 


Fig.  6. — Diagram  of  Congenital  Facial  Clefts.  Shaded  portions  indicate 
the  location  of  the  different  congenital  fissures.  EL,  harelip;  IM,  in- 
ferior maxillary  process;  LN,*,  lateral  nasal  process  of  frontal  plate; 
LN,  lateral  nasal  cleft;  MN,  middle  nasal  process  of  frontal  plate; 
OF,  oblique  facial  cleft;  SM,  superior  maxillary  process;  TF,  transverse 
facial  cleft;  *,  lower  part  of  lateral  nasal  process  which  takes  part  in 
the  formation  of  the  upper  lip,  but  not  of  its  red  border;  the  free  red 
margin  of  the  lip  is  formed  by  the  union  of  the  lower  part  of  the  middle 
nasal  process  (MN)  and  the  lower  part  of  the  superior  maxillary  process 
{SM).     (McGrath.) 

The  failure  of  the  embryonal  processes  to  coalesce  and 
the  resulting  clefts  is  due  to  deficient  development  of  the 
processes  themselves. 


Congenital  Deformities 

Congenital  deformities  of  the  face  may  be  divided  into 
two  groups : 

(a)  Those  in  which  the  frontal  plate  or  process  is  con- 
cerned. Under  this  heading  we  have — 1.  Lateral  clefts 
of  the  upper  lip  and  the  alveolar  process;  clefts  of  the 
palate  may  also  be  included  in  this  group;  2.  Median 
clefts  or  notches  of  the  upper  lip  and  deformities  of  the 


THE  DEFORMITIES  OF  THE  FACE  9 

nose;  3.  Notching  of  the  wing  of  the  nose;  4.  Oblique 
facial  clefts. 

(b)  Those  in  which  the  first  visceral  arch  is  involved. 
In  this  group  we  have — 1.  Transverse  facial  fissures;  2. 
Median  fissures  of  the  lower  lip,  lower  jaw  and  tongue; 
3.  Deformities  of  the  lower  jaw. 

Deformities  in  which  tlic  Frontal  Plate  is  Concerned 

These  are  lateral  clefts  of  the  upper  lip  and  of  the 
alveolar  process  and  cleft  palate.  Clefts  of  the  upper  lip 
and  alveolar  process  depend  upon  the  imperfect  union 
of  the  mid-nasal  process  with  the  superior  maxillary  proc- 
esses and  to  failure  of  the  maxillary  bone  and  its  accom- 
panying soft  parts  to  unite  with  the  adjoining  portion 
of  the  face.  These  clefts  are  always  lateral  and  may  be 
present  on  one  or  both  sides.  Clefts  of  the  palate  de- 
pend on  non-union  of  the  palatal  process  of  the  superior 
maxillary  process  of  either  side.  When  both  processes 
are  at  fault  the  cleft  is  median.  If  one  palatal  process 
only  is  involved  the  cleft  is  on  the  corresponding  side 
of  the  median  line,  the  opposite  palatal  process  in  this 
case  being  joined  to  the  lower  border  of  the  vomer. 

If  union  has  failed  on  both  sides  between  the  mid-nasal 
process  and  the  corresponding  part  of  the  superior  max- 
illary process  of  either  side  and  between  the  palatal  proc- 
esses of  the  superior  maxillary  processes  we  have  the 
most  extreme  variety  of  deformities.  There  are  found 
all  degrees  of  this  variety  from  a  complete  cleft  down 
to  a  notching  of  the  upper  lip,  or  a  bifurcation  of  the 
uvula. 

Harelip.  — This  condition  may  be  complete  or  incom- 
plete. Incomplete  harelip  consists  in  a  vertical  notch 
in  the  free  margin  of  the  upper  lip.  It  is  located  to  one 
side  of  the  median  line  between  the  middle  and  lateral 
segments  of  the  lip.  It  varies  from  a  slight  notch  to  a 
fissure  which  may  extend  through  the  entire  thickness  of 


10   SURGICAL  ANATOMY  OF  THE  MOUTH 


the  lip  into  the  nostril.     Harelip  may  be  associated  with 
a  cleft  of  the  alveolar  process  and  palate.    The  nose  is 


Fig.    7. — Double   Complete 
Harelip.     (McGrath.) 


Fio.  8. — Harflip  with  (A) 
Advanced  Intermaxil- 
lary Portion. 


broad  and  flat,  the  wing  of  the  affected  side  being  car- 
ried outward  away  from  the  mid-line.     The  deformity 

may  be  bilateral.  In  this 
case  the  intermaxillary 
bone  is  displaced  forward. 
Occasionally  the  entire 
middle  segment  of  the  lip 
with  the  intermaxillary 
bone  and  vomer  may  be 
absent. 

Cleft  of  the  Alveolar 
Process. — ~W  i  t  h  harelip 
there  may  be  present  a 
cleft  of  the  process  which 
varies  from  the  narrow 
fissure  to  a  broad  space; 
it  may  be  unilateral  or 
bilateral.  If  there  is  no 
cleft  of  the  hard  palate,  the  alveolar  cleft  stops  at  the  an- 
terior palatine  foramen.     If  the  cleft  in  the  process  is 


Fig.  9. — Double  Cleft  Palate  with 
Advanced  Intermaxillary  Portion 
(/.!/)  Carrying  the  Sockets  of 
Two  Incisor  Teeth.  I',  vomer 
(septum  of  the  nose).     (McGrath.) 


THE  DEFORMITIES  OF  THE  FACE  11 

bilateral  the  intermaxillary  bone  which  is  attached  to  the 
vomer  is  pushed  forward  so  that  the  median  part  of  the 
lips  projects  in  front  of  the  nose.  This  advancement  of 
the  intermaxillary  bone  is  due  to  the  unrestricted  growth 
of  the  vomer.  If  the  cleft  is  unilateral,  the  intermaxillary 
bone  becomes  twisted  and  looks  toward  the  normal  side  of 
the  face. 

Cleft  Palate. — This  is  caused  by  a  failure  of  union  of 
the  palatal  processes  in  the  median  line. 

Cleft  of  the  Hard  Palate. — This  may  be  single  or 
double;  if  one-sided  the  normal  side  is  united  with  the 
vomer,  while  on  the  affected  side  the  palate  process  is 
deficient,  leaving  an  opening  into  the  nasal  cavity.  At 
times  we  may  find  the  palatal  processes  firmly  united  but 
the  vomer  fails  to  grow  down  and  there  is  left  a  space 
below  the  lower  border  of  the  vomer  through  which  the 
two  sides  of  the  nasal  cavity  communicate  with  each 
other.  Cleft  of  the  hard  palate  ends  anteriorly  either  at 
the  anterior  palatine  foramen,  which  marks  the  point  of 
union  between  the  intermaxillary  bone  and  the  palate 
processes  of  either  side,  or  it  may  extend  through  the 
process.  It  may  be  combined  with  a  single  or  double  cleft 
of  the  alveolar  process  and  harelip.  Posteriorly  there  is 
usually  a  cleft  of  the  soft  palate. 

Cleft  of  the  Soft  Palate. — The  fissure  extends  from 
the  tip  of  the  uvula  for  a  varying  distance  into  the  soft 
palate.  It  may  be  simply  a  bifurcation  of  the  uvula,  but, 
as  a  rule,  it  extends  all  the  way  through  the  soft  palate 
as  far  as  the  posterior  border  of  the  hard  palate  or  for 
some  distance  into  the  hard  palate.  It  may  be  combined 
with  a  lateral  or  double  cleft  of  the  hard  palate.  As  is 
the  case  with  cleft  of  the  hard  palate,  there  is  not  only 
a  simple  lack  of  union  between  the  two  halves  of  the 
palate,  but  an  actual  deficiency  of  tissue  which  prevents 
the  parts  from  meeting  and  coalescing  in  the  middle  line, 
and  this  fact  is  important  in  considering  the  operative 
treatment  of  this  condition. 


12   SURGICAL  ANATOMY  OF  THE  MOUTH 

With  the  exaggerated  forms  of  cleft  palate  there  is  fre- 
quently associated  imperfect  development  of  the  mid- 
nasal  process  of  the  frontal  plate  or  it  may  be  entirely 
absent;  the  intermaxillary  bone  may  be  absent,  with  or 
without  the  absence  of  the  vomer.  If  the  intermaxillary 
bone,  etc.,  are  absent,  we  have  a  median  cleft  of  the  upper 
lip,  or,  better,  a  double  harelip  with  absence  of  its  middle 
segment.  This  state  is  usually  associated  with  a  broad 
cleft  in  the  hard  and  the  soft  palate,  and  the  nose  may 
be  soft  and  flattened,  on  account  of  the  absence  of  the 
nasal  septum,  etc.  The  latter  condition  is  apt  to  be  ac- 
companied by  defective  cerebral  development. 

Median  Clefts  and  Notches  of  the  Upper  Lip.— These 
deformities  depend  upon  exaggeration  and  persistence  of 
the  embryonal  notch  of  the  middle  portion,  the  mid-nasal 
process,  of  the  frontal  plate  and  failure  of  the  nostrils 
to  approach  each  other.  These  defects  are  much  less 
frequent  than  the  preceding.  There  may  be  simply  a 
notch  or  fissure  in  the  middle  of  the  upper  lip  reaching 
part  way  through,  or  this  may  be  combined  with  a  groov- 
ing or  furrow  upon  the  point  and  dorsum  of  the  nose 
and  a  wide  separation  between  the  nostrils.  This  condi- 
tion may  be  so  pronounced  that  the  nose  appears  to  con- 
sist of  two  halves  completely  separated  from  each  other 
and  each  containing  one  nostril.  Instead  of  this  extreme 
degree  of  deformity  the  nose  may  be  simply  flattened, 
the  bridge  depressed,  the  nostrils  far  apart  and  looking 
directly  forward,  "dog  nose."  The  fissure  in  the  upper 
lip,  instead  of  simply  notching  the  lip,  may  extend  com- 
pletely through  the  whole  lip  and  into  the  intermaxillary 
bone.  This  variety  of  deformity  may  also  be  represented 
by  a  fistula  of  the  tip  of  the  dorsum  of  the  nose. 

Lateral  Nasal  Clefts.— These  occur  with  or  without 
harelip  and  cleft  palate ,  the  notch  or  fissure  in  this  case 
involving  the  wing  of  the  nose.  If  they  extend  upward 
for  a  considerable  distance  through  the  side  of  the  nose, 
they  terminate  above,  not  in  the  inner  canthus,  but  to  the 


THE  DEFORMITIES  OF  THE  FACE 


13 


inner  side  of  the  inner  corner  of  the  eye ;  they  represent 
the  embryonal  notch  between  the  middle  and  lateral  nasal 
processes  of  the  frontal  plate.  Fissures  of  the  side  of 
the  nose  that  resemble  these,  but  terminate  above  in 
the  inner  canthus  of  the  eye,  are  varieties  of  oblique 
clefts. 

Oblique  Facial  Clefts.— Failure  of  normal  union  be- 
tween the  lateral  process  of  the  frontal  plate  and  the 
superior  maxillary  process 
of  the  first  visceral  arch 
produces  these  deformities. 
They  correspond  to  the  em- 
bryonal orbitonasal  line  of 
coalescence.  These  deformi- 
ties may  be  very  extensive  or 
slight,  one-sided  or  double. 
They  commence  below  at  the 
edge  of  the  upper  lip,  and, 
after  splitting  this  at  the 
usual  harelip  site,  extend  up- 
ward through  the  cheek  and 
alongside  of  the  wing  of  the 
nose,  not  into  the  nostril  like 
a  harelip,  terminating  above 
at  the  lower  margin  of  the 
eye  (lower  lid)  or  inner  can- 
thus.  They  may  extend  be- 
yond the  orbit,  from  its  outer  corner,  upward  and  out- 
ward into  the  frontotemporal  region  of  the  skull.  They 
vary  from  a  narrow  fissure  or  incomplete  notch  to  a  wide 
gaping  fissure,  between  the  edges  of  which  is  the  eyeball. 
This  class  of  deformity  is  frequently  represented  in  its 
simplest  form  by  a  notch  or  coloboma  of  the  lower  or 
upper  eyelid.  Instead  of  a  fissure,  this  deformity  may 
be  represented  by  a  cicatricial,  nodulated  seam,  indicat- 
ing the  orbitonasal  junction. 


Fig.  10. — Incomplete  Oblique  Fa- 
cial Cleft.  The  edge  of  the  up- 
per lip  is  notched  and  a  cicatri- 
cial line  extends  across  the  cheek 
to  the  lower  eyelid,  which  is 
everted.     (McGrath.) 


14      SUEGICAL  ANATOMY  OF  TIIU  JMOUTll 


Deformities  in  which  the  First  Visceral  Arch  is 
Involved 

Transverse  Facial  Clefts.— These  are  due  to  a  failure 
of  the  inferior  maxillary  process  of  the  first  visceral 
arch  and  its  superior  maxillary  process  to  coalesce  the 
normal  extent.  This  deformity  may  be  unilateral  or 
double.     The  cleft  extends  from  the  corner  of  the  mouth 

outward  through  the  cheek  and 
exposes  the  teeth  (maeros- 
toma).  If  the  reverse  of  this 
process  occurs,  we  may  have  a 
mouth  so  small  as  to  require 
surgical  interference  (micros- 
toma).    {See  Fig.  4.) 

Median  Clefts  of  the  Lower 
Lip,  Lower  Jaw,  and  Tongue. 
— These  conditions  are  very 
rare.  They  are  due  to  failure 
of  the  two  halves  of  the  first 
visceral  arch  (mandibular  pro- 
cess) to  unite  with  each  other 
in  the  middle  line.  They  vary 
from  a  slight  notching  of  the 
lower  lip,  in  the  middle  line,  to  a  complete  separation 
through  the  lowTer  lip,  the  lower  jaw  at  the  symphysis, 
and  the  tongue.  The  tongue,  by  itself,  may  be  split  or 
absent  or  bound  down  to  the  floor  of  the  mouth  or  ad- 
herent to  the  side  of  the  cheek,  etc. 

The  lower  jaw  may  be  imperfectly  developed,  rudimen- 
tary, etc.  It  may  be  split  in  the  middle  line  or  there  may 
be  absence  of  the  condyles,  etc.  As  the  formation  of  the 
face  advances  the  jaw  is  gradually  protruded  forward, 
and,  if  arrested,  we  have,  as  a  result,  the  receding  chin, 
etc. 


Fig.    11. — Transverse    Facial 
Cleft.     (McGrath.) 


CEAXIAL  AND  FACIAL  BONES  15 

CRANIAL  AND  FACIAL  BONES 

The  Skull 

The  term  skull  is  used  to  describe  the  entire  skeleton  of 
the  head.  It  comprises  the  cranium,  that  part  surround- 
ing the  brain,  and  the  bones  which  go  to  form  the  face. 

Bones  of  the  Cranium.        Bones  of  the  Face. 


1 
1 

Sphenoid 
Ethmoid 

1    Vomer 

1    Inferior  Maxilla 

1 
1 

2 

Frontal 

Occipital 

Parietals 

2    Superior  Maxillary  bones 
2    Nasal 
2    Lacrimal 

>> 

Temporals 

2    Malar 

2    Inferior  Turbinates 

2    Palate  bones 

The  hyoid  bone  and  the  ossicles  of  the  ear  (malleus,  in- 
cus and  stapes)  are  usually  described  with  the  bones  of 
the  skull. 

Frontal  Bone 

The  frontal  bone  forms  the  front  of  the  cranium  and 
the  roof  of  the  orbits.  It  presents  for  examination  an 
external,  inferior,  and  an  internal  or  cerebral  surface. 
The  external  surface  exhibits  the  following  points  for 
examination:  Two  convexities  known  as  the  frontal 
eminences,  below  which  are  the  superciliary  ridges.  Be- 
tween the  superciliary  ridges  is  a  prominence  called  the 
glabella.  The  orbital  arches  or  margins  end  externally 
and  internally  as  the  external  and  internal  angular  proc- 
esses. Near  the  inner  end  is  the  supra-orbital  notch. 
The  temporal  crest  separates  the  frontal  from  the  tem- 
poral part  of  the  bone  and  is  continuous  with  the  tem- 
poral line  of  the  temporal  bone. 

The  inferior  or  orbital  surfaces  are  triangular  in  shape 


16     SURGICAL  ANATOMY  OF  THE  MOUTH 

and  are  separated  by  the  nasal  notch  in  front  and  the 
ethmoidal  notch  behind.  From  the  nasal  notch  projects  a 
sharp  point  of  bone  called  the  nasal  spine.  Between  the 
orbital  surfaces  and  the  ethmoidal  notch  is  a  rough  area 
of  bone  which  forms  the  roof  of  the  ethmoidal  cells  and 
presents  two  grooves,  which  complete,  with  the  ethmoid 
bone,  the  posterior  and  anterior  ethmoid  cells.  Far  for- 
ward is  an  opening  into  the  frontal  sinus,  a  cavity  in 
the  bone.  The  smooth  orbital  surface  presents  exter- 
nally the  lacrimal  fossa  and  internally  a  depression  called 
the  trochlear  fossa. 

The  internal  or  cerebral  surface  is  concave,  except  over 
the  roofs  of  the  orbits,  where  it  is  convex.  It  is  marked 
by  depressions  in  which  are  lodged  the  convolutions  of 
the  brain.  In  the  median  line,  the  frontal  sulcus  descends 
from  the  middle  of  the  upper  margin  of  the  bone  and 
terminates  below  as  the  frontal  crest ;  this  groove  or 
sulcus  lodges  the  superior  longitudinal  sinus.  At  the 
base  of  the  frontal  crest  is  the  foramen  cecum.  On  each 
side  are  several  fine  furrows  which  are  occupied  by  the 
meningeal  vessels  which  supply  the  meninges  or  cover- 
ings of  the  brain. 


l& 


Paeietal  Bones 

The  parietal  bones  are  quadrilateral  in  shape  and  pre- 
sent an  external  convex  surface,  an  internal  concave  sur- 
face and  four  rough  borders.  They  form  a  large  part 
of  the  vault  of  the  skull. 

Externally  are  the  parietal  eminences,  below  which 
are  the  superior  and  inferior  temporal  lines;  below  the 
latter  is  the  temporal  surface  which  forms  part  of  the 
temporal  fossa.  The  internal  surface  is  concave  and,  like 
the  frontal  bone,  is  marked  by  the  convolutions  of  the 
brain,  and  here  are  seen  several  fine  grooves  which 
lodge  the  meningeal  vessels.  The  largest  of  these  begins 
at  the  anterior  inferior  angle,  passes  upward  and  back- 
ward and  is  occupied  by  the  middle  meningeal  artery. 


CRANIAL  AND  FACIAL  BONES  17 

At  the  posterior  inferior  angle  is  a  groove  for  the  lateral 
sinus.  Above,  running  along  the  superior  border,  is  a 
groove  for  the  superior  longitudinal  sinus. 

Temporal  Bones 

The  temporal  bone  is  described  in  three  parts:  (a)  the 
squamozygomatic,  which  is  the  expanded  anterior  por- 
tion; (b)  the  mastoid,  which  is  the  thickened  posterior 
part;  (c)  the  petrous  portion,  which  intervenes  between 
the  two,  presents  externally  the  opening  of  the  ear,  from 
which  point  it  projects  inward  and  assists  in  the  forma- 
tion of  the  base  of  the  skull. 

The  squamous  portion  projects  upward  and  forward, 
being  limited  by  a  thin  sharp  border  which  forms  about 
two-thirds  of  a  circle.  The  inner  surface  is  marked  by 
cerebral  depressions  and  by  several  meningeal  grooves; 
at  the  lower  part  there  is  usually  a  fissure  which  marks 
the  line  of  separation  between  the  petrous  and  the  squa- 
mous portions  of  the  bone.  The  outer  surface  is  slightly 
convex  and  forms  a  part  of  the  temporal  fossa.  From 
the  lower  part  of  this  surface  projects  the  zygoma,  which 
is  at  first  directed  outward  and  forward,  terminating  in 
a  serrated  edge  for  articulation  with  the  malar  bone. 
Posteriorly  the  zygoma  springs  from  two  roots,  an  an- 
terior and  a  posterior,  between  which  is  a  hollow  called 
the  glenoid  fossa;  this  fossa  is  divided  into  two  parts 
by  the  fissure  of  Glaser.  The  posterior  portion  formed 
by  the  tympanic  plate  is  non-articular.  The  anterior 
part,  covered  with  cartilage  in  the  natural  state,  articu- 
lates with  the  condyle  of  the  lower  jaw.  In  front  of 
the  articular  area  is  a  triangular  surface  Which  forms  a 
part  of  the  zygomatic  fossa. 

The  mastoid  portion  projects  downward  externally  into 
the  mastoid  process;  this  process  has  on  its  inner  sur- 
face a  groove  called  the  digastric  groove,  internal  to 
which  is  the  occipital  groove  for  the  occipital  artery. 


18      SUEGICAL  ANATOMY  OF  THE  MOUTH 

The  internal  or  cerebral  surface  is  marked  by  a  depres- 
sion which  is  a  portion  of  the  groove  for  the  lateral  sinus. 

The  petrous  portion  is  pyramidal  in  shape  and  con- 
tains the  organ  of  hearing.  It  presents  a  base,  two  in- 
ternal or  cerebral  surfaces,  an  external  or  inferior  sur- 
face and  an  apex.  The  base  appears  externally  between 
the  squamous  and  mastoid  portions  of  the  bone  as  the 
external  auditory  meatus  which  leads  into  the  middle 
ear  or  tympanum.  The  meatus  is  bounded  above  by  the 
posterior  root  of  the  zygoma,  while  all  of  the  other  boun- 
daries are  formed  by  the  auditory  process,  the  thickened 
edge  of  the  tympanic  plate.  The  tympanic  plate  forms 
the  anterior  and  inferior  wall  of  the  external  auditory 
meatus  and  the  tympanum.  The  external  surface  looks 
toward  the  glenoid  fossa,  while  its  lower  edge  surrounds 
the  styloid  process.  The  styloid  process  is  long  and 
tapering  and  between  this  and  the  mastoid  process  is  the 
stylomastoid  foramen  through  which  passes  the  facial 
nerve.  Internal  to  the  stylomastoid  foramen  is  the  jugu- 
lar facet,  which  articulates  with  the  occipital  bone.  In 
front  of  this  is  the  jugular  fossa  which,  with  the  jugular 
notch  of  the  occipital  bone,  forms  the  jugular  foramen. 
In  front  of  the  jugular  fossa  is  the  carotid  foramen  lead- 
ing into  the  carotid  canal,  which  passes  upward  and  then 
inward  to  emerge  at  the  apex  of  the  petrous  portion. 

The  posterior  surface  forms  part  of  the  posterior 
fossa  of  the  skull.  About  the  center  of  the  surface  is 
the  internal  auditory  meatus,  into  which  pass  the  facial 
and  auditory  nerves. 

The  superior  surface  forms  part  of  the  middle  fossa 
of  the  skull.  A  depression  near  the  apex  marks  the 
situation  of  the  gasserian  ganglion.  The  superior  bor- 
der is  grooved  for  the  superior  petrosal  sinus.  The  an- 
terior border  is  short,  and  in  the  angle  between  it  and 
the  squamous  portion  is  seen  the  opening  of  the  eus- 
tachian canal,  a  part  of  the  eustachian  tube  which  leads 
from  the  middle  ear  to  the  pharynx.    The  posterior  bor- 


CRANIAL  AND  FACIAL  BONES  19 

der  articulates  with  the  occipital  hone  and  forms  with  it 
a  groove  for  the  inferior  petrosal  sinus. 

Occipital,  Bone 

The  occipital  bone  is  situated  at  the  back  part  of  the 
head  and  forms  a  portion  of  the  base  of  the  skull.  It  is 
irregularly  quadrilateral  in  shape  and  is  pierced  in  its 
anterior  portion  by  the  foramen  magnum  (through  the 
foramen  magnum  pass  the  spinal  cord,  vertebral  arte- 
ries and  the  spinal  portion  of  the  spinal  accessory  nerve). 
That  portion  of  the  bone  in  front  of  the  foramen  magnum 
is  called  the  basilar  portion;  that  behind,  the  tabular 
portion  and  on  either  side  are  the  condylar  portions. 
On  the  condylar  portions  are  placed  the  condyles,  or 
articular  processes,  by  which  the  head  is  supported  on 
the  atlas.  Two  superior  borders  of  the  bone  articulate 
with  the  parietal  bones,  the  inferior  borders  with  the 
temporal  bone,  while  the  basilar  process  is  joined  to  the 
body  of  the  sphenoid  by  cartilage.  The  tabular  portion, 
externally,  presents  about  its  center  a  prominence,  the 
external  occipital  protuberance.  Extending  laterally 
from  this  eminence  are  two  ridges  of  bone  called  the 
superior  curved  lines.  A  little  above  these  on  each  side 
is  the  less  prominent  linea  suprema.  Above  this  the 
bone  is  smooth,  while  below  it  is  irregular  and  is  di- 
vided into  two  lateral  halves  by  a  median  ridge,  called 
the  external  occipital  crest.  These  lateral  portions  are 
divided  into  an  upper  and  lower  part  by  the  inferior 
curved  lines. 

The  internal  surface  is  marked  by  two  ridges  which 
cross  each  other  at  right  angles.  One  passes  from  the 
foramen  magnum  to  the  superior  angle,  the  other  later- 
ally between  the  two  lateral  angles.  The  internal  occipi- 
tal protuberance  is  at  the  point  of  crossing.  The  in- 
ternal surface  is  thus  divided  into  four  fossae;  the  su- 
perior and  inferior  occipital  fossae.    The  superior  parts 


20      SURGICAL  ANATOMY  <>F  THE  MOUTH 

of  the  vortical  and  the  transverse  ridges  arc  grooved  for 
the  superior  longitudinal  and  lateral  sinuses  respectively. 
The  lower  half  of  the  vertical  ridge  is  called  the  internal 
occipital  crest. 

The  condylar  portion  externally  supports  the  condyles 
which  are  the  elliptical  articulating  surfaces  (processes) 
by  which  the  head  is  supported  on  the  atlas.  In  front 
and  external  to  the  condyle  is  the  anterior  condyloid 
foramen  which  transmits  the  hypoglossal  nerve.  Pos- 
teriorly is  the  posterior  condyloid  foramen  which  trans- 
mits a  small  vein.  External  to  the  condyle  is  the  jugular 
process  which  has  the  jugular  notch  in  front.  This  notch 
with  the  corresponding  one  on  the  temporal  bone  forms 
the  jugular  foramen  in  the  articulated  skull.  The  inter- 
nal surface  of  the  jugular  process  is  grooved  for  the 
lateral  sinus. 

The  basilar  process  projects  upward  and  forward  and 
is  joined  to  the  body  of  the  sphenoid.  Externally  it  pre- 
sents the  pharyngeal  tubercle.  Internally  is  the  basilar 
groove  in  the  median  line,  and  laterally  near  the  margin 
on  either  side  is  a  groove  for  the  inferior  petrosal  sinus. 

The  Ethmoid 

The  ethmoid  consists  of  a  vertical  plate  and  twTo  lateral 
masses  which  are  united  at  their  superior  borders  by 
the  horizontal  cribriform  plate.  The  vertical  plate  lies  in 
the  median  line  and  forms  the  upper  third  of  the  nasal 
septum.  In  front  it  rises  above  the  cribriform  plate  as 
the  crista  galli,  a  thick  process  of  bone,  to  which  is  at- 
tached the  falx  cerebri.  The  anterior  edge  of  crista  galli 
is  divided  into  twTo  alae  (wings)  which  articulate  with 
the  frontal  bone.  The  two  alae  are  separated  by  a  groove 
which  in  the  articulated  skull  forms  the  foramen  cecum. 
Below  the  cribriform  plate  the  vertical  plate  articulates 
anteriorly  with  the  nasal  spine  of  the  frontal  bone  and 
with  the  nasal  bones.    Inferiorly  it  articulates  with  the 


CRANIAL  AND  FACIAL  BONES  21 

triangular  cartilage  of  the  nose,  posteriorly  with  the 
vomer  and  the  crest  of  the  sphenoid. 

The  lateral  masses  are  composed  of  a  number  of  cellu- 
lar spaces  which  are  lined  with  prolongations  of  nasal 
mucous  membrane.  The  external  wall  is  a  smooth  bony 
plate,  the  os  planum,  which  closes  in  part  of  the  cellular 
spaces  and  forms  a  portion  of  the  inner  wall  of  the 
orbit.  In  front  of  the  os  planum  some  of  the  cellular 
spaces  known  as  the  anterior  ethmoidal  cells  are  under 
cover  of  the  lacrimal  bone.  From  this  portion  extend- 
ing downward  and  backward  is  the  uncinate  process.  At 
the  lower  part  of  this  aspect  is  a  groove  which  in  the 
articulated  skull  is  the  middle  meatus  of  the  nose.  This 
is  limited  below  by  the  edge  of  the  inferior  turbinated 
process. 

Anteriorly  this  groove  is  continued  upward  into  a 
canal,  the  infundibulum,  which  leads  through  the  anterior 
ethmoidal  cells  into  the  frontal  sinus.  The  internal  aspect 
of  each  lateral  mass  forms  a  portion  of  the  outer  wall 
of  the  nose.  Posteriorly  it  is  divided  by  a  groove,  the 
superior  meatus,  which  runs  forward  to  about  the  middle 
of  the  inner  surface.  Above  this  groove  is  a  small  pro- 
jecting shelf  of  bone,  the  superior  turbinated  bone  (or 
process).  Below  this  groove  is  another  projecting  plate 
called  the  middle  turbinated  bone  (or  process).  The  su- 
perior border  of  each  lateral  mass  is  covered  by  the  orbi- 
tal plate  of  the  frontal  bone,  the  anterior  border  by  the 
nasal  process  of  the  upper  jaw,  and  the  posterior  border 
by  the  body  of  the  sphenoid.  The  lower  border  is  formed 
by  the  free  edge  of  the  middle  turbinated  bone.  The 
cribriform  plate  fits  into  the  ethmoidal  notch  of  the  fron- 
tal bone.  On  either  side  of  the  crista  galli  are  the  olfac- 
tory grooves  which  lodge  the  olfactory  lobes  of  the  brain. 
The  olfactory  grooves  are  pierced  by  numerous  foramina 
for  the  olfactory  nerves;  at  the  anterior  end  of  the  ol- 
factory groove  is  a  small  slit  on  each  side  of  the  crista 
galli  which  transmits  the  nasal  nerve. 


22      SUEGICAL  ANATOMY  OF  THE  MOUTH 

Sphenoid 

The  sphenoid  is  so  called  because  it  is  wedged  into  the 
base  of  the  skull  between  the  other  bones.  It  resembles  a 
bat  with  extended  wings,  so  wre  can  shape  our  descrip- 
tion accordingly.  It  presents  :  (a)  a  body  or  central  part; 
(/>)  two  greater  wings;  (c)  two  lesser  wings;  (d)  two 
pterygoid  processes. 

Body.  — The  superior  surface  comprises  what  is  seen 
inside  of  the  base  of  the  skull.  There  is  a  deep  depression 
in  it,  called  the  pituitary  fossa  or  sella  turcica,  which 
lodges  the  pituitary  body.  In  front  of  this  is  the  olivary 
process,  a  rounded  eminence,  on  which  rests  the  optic 
commissure,  which  makes  a  transverse  groove  leading 
on  either  side  to  the  optic  foramen.  In  front  of  the  oli- 
vary process  is  a  smooth,  slightly  concave  surface  which 
supports  the  olfactory  lobes  and  terminates  anteriorly  in 
the  ethmoidal  spine.  Behind  the  sella  turcica  is  the  dor- 
sum sellae,  the  posterior  surface  of  which  is  continuous 
with  the  basilar  process  of  the  occipital  bone.  The  angles 
of  this  process  which  project  over  the  pituitary  fossa 
are  called  the  posterior  clinoid  processes.  Laterally  this 
surface  shows  a  winding  groove  on  either  side  for  the 
carotid  artery. 

The  posterior  surface  is  united  to  the  basilar  process 
of  the  occipital  bone. 

The  anterior  surface  is  marked  in  the  median  line  by 
the  sphenoidal  crest  which  articulates  with  the  vertical 
plate  of  the  ethmoid.  The  surface  on  each  side  of  the 
crest  is  divided  into  a  median  portion  which  forms  part 
of  the  roof  of  the  nasal  fossae,  and  a  lateral  part  which 
articulates  with  the  ethmoid  and  palate  bones.  The  me- 
dian portion  presents  near  its  upper  part  the  opening  of 
the  sphenoidal  sinus,  which  is  a  cavity  in  the  body  of 
the  bone. 

The  inferior  surface  presents  anteriorly  the  rostrum, 
a  ridge  of  bone  which  is  continuous  with  the  sphenoidal 


CRANIAL  AND  FACIAL  BONES  23 

crest  of  the  anterior  surface.  Projecting  horizontally  in- 
ward from  the  pterygoid  processes  on  each  side  are  the 
two  vaginal  processes. 

Greater  and  Lesser  Wings.— The  lateral  surfaces  form 
the  attachment  for  the  greater  and  lesser  wings.  Ante- 
riorly below  the  root  of  the  lesser  wing  is  a  small  free 
surface  which  forms  the  inner  boundary  of  the  sphenoi- 
dal fissure  and  the  posterior  part  of  the  inner  wall  of 
the  orbit. 

The  lesser  wing  projects  horizontally  from  the  anterior 
part  of  the  superior  surface  of  the  body.  The  upper 
surface  of  the  lesser  wing  forms  a  portion  of  the  an- 
terior fossa  of  the  skull.  Externally  this  surface  ter- 
minates in  a  pointed  extremity  which  nearly  touches  the 
greater  wing  below.  Interiorly  the  sphenoidal  fissure 
and  the  back  part  of  the  orbit  are  roofed  over  by  this 
process.  The  anterior  border  articulates  with  the  orbital 
plate  of  the  frontal  bone.  The  posterior  border  forms 
the  anterior  boundary  of  the  middle  fossa  of  the  skull 
and  ends  internally  as  the  anterior  clinoid  process.  Be- 
tween the  anterior  clinoid  process  and  the  olivary  emi- 
nence is  the  carotid  groove,  and  in  front  of  this  is  the 
optic  foramen. 

The  greater  wings  project  upward  and  outward  from 
the  body;  each  wing  also  extends  backward  as  a  projec- 
tion called  the  spine.  They  exhibit  three  surfaces  for 
examination:  1,  superior  or  cerebral  surface;  2,  inferior 
or  temporozygomatic  surface ;  3,  anterior  or  orbital  sur- 
face. 

The  superior  or  cerebral  surface  is  slightly  concave. 
It  is  situated  in  a  line  passing  forward  and  inward  from 
the  spine  to  the  inner  end  of  the  sphenoidal  fissure  and 
several  foramina.  1.  Piercing  it  is  the  foramen  spinosum 
which  transmits  the  middle  meningeal  artery.  2.  In 
front  of  this  is  the  foramen  ovale,  through  which  passes 
the  third  division  of  the  fifth  nerve  (inferior  maxillary 
division  of  the  fifth).     3.  Internal  and  anterior  to  the 


24   SURGICAL  ANATOMY  OF  THE  MOUTH 

foramen  ovale  is  the  foramen  rotundum,  through  which 
passes  the  second  division  of  the  fifth  nerve  (superior 
maxillary  division  of  the  fifth). 

The  inferior  or  temporozygomatic  surface  is  divided 
into  two  parts  by  the  infratemporal  crest.  The  upper 
surface  forms  part  of  the  temporal  fossa  and  the  lower 
looks  downward  into  the  zygomatic  fossa. 

Internally  this  surface  exhibits  the  external  aspect  of 
the  foramen  ovale  and  the  foramen  spinosum. 

The  anterior  surface  looks  forward  and  forms  part  of 
the  outer  wall  of  the  orbit ;  a  small  portion  of  this  surface 
looks  downward  into  the  sphenomaxillary  fossa  and  is 
perforated  by  the  foramen  rotundum. 

The  sphenoidal  fissure  (foramen  lacerum  anterius)  in- 
tervenes between  the  greater  and  lesser  wings  and  is 
widest  at  its  lower  end.  The  third,  fourth,  sixth,  and 
the  first  division  of  the  fifth  (ophthalmic)  nerves 
and  the  ophthalmic  vein  have  their  exit  through  this  fis- 
sure. 

Pterygoid  Processes. — The  pterygoid  processes  project 
downward  from  the  body  and  the  adjacent  portion  of  the 
greater  wings.  Each  consists  of  an  external  and  internal 
plate,  united  at  an  angle  so  as  to  enclose  between  them 
the  pterygoid  fossa.  The  external  plate  is  shorter  than 
the  internal,  and  its  external  surface  forms  a  portion 
of  the  zygomatic  fossa.  The  internal  plate  terminates 
below  in  a  hook-like  process  called  the  hamular  process. 
Superiorly  the  internal  plate  curves  under  the  body  and 
ends  as  a  thin  plate  of  bone  called  the  vaginal  process, 
which  articulates  with  the  vomer.  A  little  external 
to  this  thin  edge  is  a  groove  which  contributes  with 
the  palate  bone  to  form  the  pterygopalatine  canal. 
Posteriorly  is  seen  the  pterygoid  tubercle,  which  is 
to  the  inner  side  of  and  below  the  orifice  of  the  vidian 
canal. 


BONES  OF  THE  FACE 


25 


BONES  OF  THE  FACE 


The  Superior  Maxilla 

The  superior  maxilla  consists  of  a  body  and  four  proc- 
esses. The  body  offers  for  examination  an  external  or 
facial  surface,  an  internal  or  nasal  surface,  and  a  supe- 
rior or  orbital  surface. 
The  processes  are  the  na- 
sal, projecting  upward; 
the  alveolar,  which  con- 
tains the  teeth  sockets; 
and  the  malar,  which  di- 
vides the  external  surface 
into  an  anterior  or  facial 
surface,  and  a  posterior 
or  zygomatic  surface;  fi- 
nally, the  palate  process 
projects  horizontally  on 
the  inner  side  of  the  body. 

Body.— The  body  is  hol- 
lowed into  a  cavity  called 
the  antrum  of  Highmore 
which  opens  on  the  inner 
ride  into  the  nasal  fossa. 
The  facial  surface  is  con- 
tinuous below  with  the  al- 
veolar process,  and  is 
marked  by  t  ridges  which 
correspond  in  position  with  the  roots  of  the  teeth;  that 
of  the  canine  tooth  is  very  prominent  and  separates  the 
incisive  fossa  from  the  canine  fossa.  Above  the  canine 
fossa  is  the  infra-orbital  foramen  which  transmits  the  in- 
fra-orbital vessels  and  nerve.  The  zygomatic  surface 
is  the  posterior  external  surface  lying  behind  the  malar 
process.  It  shows  the  openings  of  the  posterior  den- 
tal canals  which   transmit   the  posterior  dental   nerves. 


Fig.  12. — Antrum  op  Highmore. 
White  arrow,  natural  drainage; 
black  arrow,  surgical  drainage. 
(Campbell.) 


26      SURGICAL  ANATOMY  OF  THE  MOUTH 


The  nasal  surface  anteriorly  presents  the  inferior  tur- 
binated crest  which  articulates  with  the  inferior  turbin- 
ated bone.  Below  this  crest  is  the  inferior  meatus,  and 
above  it  the  middle  meatus  of  the  nose.  Behind  the 
nasal  process  lies  the  lacrimal  groove,  which  is  con- 
verted into  a  canal,  the  nasal  duct  (tear  duct),  by  the 
lacrimal  and  inferior  turbinated  bones.  Posterior  to  the 
lacrimal  groove  is  the  opening  into  the  antrum  of  High- 
more.  Posterior  to  this 
opening  is  a  rough  sur- 
f  a  c  e  for  articulation 
with  the  palate  bone. 
Crossing  the  lower  part 
of  this  articular  surface 
and  passing  downward 
and  forward  is  a  groove, 
completing  with  the  pal 
ate  bone  the  posterior 
palatine  canal. 

The  orbital  surface  is 
triangular  and  smooth. 
The  chief  feature  of 
this  surface  is  the  infra- 
orbital groove,  which, 
passing  from  behind 
forward,  into  a  canal  of 
the  same  name,  transmits  the  infra-orbital  nerve  and  ves- 
sels. On  the  internal  border  of  this  surface,  behind  the 
nasal  process,  is  the  lacrimal  notch  for  the  lacrimal 
bone. 

Processes.— The  nasal  process  passes  upward  from  the 
anterior  part  of  the  body.  It  requires  no  special  descrip- 
tion. 

The  alveolar  process  is  thick  and  is  hollowed  out  into 
sockets  for  the  teeth. 

The  malar  process  is  thick  and  triangular  and  divides 
the  external  surface  into  an  anterior  or  facial  surface, 


Fig.    13. — Antrum    of    Highmore    and 
Surface  Location.     (Campbell.) 


BONES  OF  THE  FACE  27 

and  a  posterior  or  zygomatic  surface.  Its  rough  surface 
is  for  articulation  with  the  malar  bone. 

The  palate  process  forms  about  three-fourths  of  the 
hard  palate,  the  remainder  being  formed  by  the  palate 
process  of  the  palate  bone.  The  upper  surface  is  smooth, 
and  the  lower,  grooved  and  rough.  The  mesial  border 
rises  into  a  vertical  ridge  which  with  its  fellow  of  the 
opposite  side,  forms  the  nasal  crest  for  articulation  with 
the  vomer.  Anteriorly  this  crest  is  more  prominent  than 
elsewhere.  On  the  outer  side  of  the  incisor  crest  on  the 
upper  surface  is  a  foramen,  leading  into  a  canal  which 
opens  on  the  lower  surface  into  the  anterior  palatine 
fossa. 

The  antrum  of  Highmore  is  a  cavity  occupying  the 
body  of  the  maxilla.  It  is  pyramidal  in  form,  the  base 
being  toward  the  nasal  surface  and  the  apex  toward  the 
malar  process.  In  the  articulated  skull  the  aperture 
opening  on  the  nasal  surface  is  nearly  closed  by  the  eth- 
moid, the  palate  and  the  inferior  turbinated  bone. 

The  Palate  Bone 

The  palate  bone  (in  two  parts)  forms  part  of  the  hard 
palate  and  lateral  wall  of  the  nose.  It  consists  of  a  hori- 
zontal and  a  vertical  plate,  united  at  a  right  angle.  In 
addition  there  are  three  processes:  (a)  tuberosity;  (b) 
orbital;  (<?)  sphenoidal. 

Plates.  — The  horizontal  plate  forms  the  posterior  por- 
tion of  the  hard  palate  and  articulates  anteriorly  with  the 
palate  process  of  the  upper  jaw.  Its  upper  surface  con- 
tributes to  the  formation  of  the  back  part  of  the  nasal 
fossa.  The  posterior  border  is  free,  concave,  and  gives 
attachment  to  the  soft  palate.  The  internal  border  ar- 
ticulates with  the  opposite  bone,  forming  a  continuation 
of  the  nasal  crest  of  the  upper  jaw. 

The  vertical  plate  has  an  internal  or  nasal  surface,  and 
an  external  surface.     The  nasal  surface  is  divided  into 


2S      SURGICAL  ANATOMY  OF  TIIF   MOFTIT 


an  upper  and  lower  portion  by  the  inferior  turbinated 
crest,  which  articulates  with  the  inferior  turbinated  bone. 
These  two  surfaces  are  continuous  with  similar  ones  on 
the  upper  jaw,  forming  the  inferior  and  middle  meatus  of 
the  nose.  At  the  upper  end  of  the  upper  surface  is  an- 
other ridge,  the  superior  turbinated  crest,  which  articu- 
lates with  the  middle  tur- 
binated bone.  The  exter- 
nal surface  presents  a 
groove  which  forms  with 
the  superior  maxilla,  the 
posterior  palatine  canal 
for  the  large  palatine 
vessels  and  nerve.  The 
greater  part  of  the  sur- 
face articulates  with  the 
upper  jaw. 

Processes.  —  (a)  The 
tuberosity  fits  into  the 
notch  between  the  ptery- 
goid plates  and  com- 
pletes the  pterygoid  fos- 
sa; (b)  the  orbital  pro- 
cess lies  at  the  anterior 
superior  portion  of  the  vertical  plate  and  forms  part  of 
the  floor  of  the  orbit;  (c)  the  sphenoidal  process  arises 
from  the  posterior  superior  part  of  the  vertical  plate.  Its 
upper  surface  is  in  contact  with  the  body  of  the  sphenoid, 
its  internal  surface  looks  toward  the  nasal  fossa,  and  its 
base  looks  into  the  sphenomaxillary  fossa.  The  orbital 
and  sphenoidal  processes  are  separated  by  the  spheno- 
palatine notch. 

The  Malar  Bone 


Fig.  14. — Showing  the  Incomplete 
Fusion  of  the  Palatal  Plates 
and  the  v-shaped  interval  filled 
by  the  Intermaxillary  Bone.  A, 
median  articulation ;  B,  intermaxil- 
lary  bone.      (Campbell.) 


The  malar  bone  is  quadrangular  in  shape  and  forms 
the  prominence  of  the  cheek.  The  external  surface  is  con- 
vex and  the  internal  concave.    The  latter  looks  into  the 


BONES  OF  THE  FACE  29 

temporal  and  zygomatic  fossae.  The  upper  angle  articu- 
lates with  the  external  angular  process  of  the  frontal 
bone.  The  temporal  border  passes  backward  and  down- 
ward to  the  temporal  process  which  articulates  with  the 
zygomatic  process  of  the  temporal  bone.  The  posterior 
inferior  border  is  roughened  for  the  attachment  of  the 
masseter  muscle.  The  anteroinferior  border  is  rough 
and  serrated  for  articulation  with  the  upper  jaw.  The 
orbital  border  is  continuous  with  the  orbital  process 
which  forms  a  portion  of  the  outer  wall  of  the  orbit.  The 
orbital  process  projects  backward  and  inward  and  articu- 
lates with  the  greater  wing  of  the  sphenoid. 

The  Turbinates 

The  two  upper  turbinates  are  part  of  the  ethmoid.  The 
lower  is  a  distinct  bone  and  is  the  largest  of  the  three. 
It  is  a  thin  plate  of  bone  consisting  of  a  body  and  three 
processes ;  the  anterior  part  articulates  with  the  inferior 
turbinated  crest  of  the  superior  maxilla  and  the  posterior 
part  with  a  similar  crest  on  the  palate  bone. 

The  maxillary  process  extends  downward.  It  is  the 
largest  of  the  three  processes  and  partly  closes  the  orifice 
of  the  antrum  of  Highmore.  The  lacrimal  articulates 
with  the  lower  part  of  the  lacrimal  bone  and  forms  part 
of  the  wall  of  the  nasal  duct.  The  ethmoidal  process 
passes  backward  and  upward,  articulating  with  the  un- 
cinate process  of  the  ethmoid. 

The  Lacrimal  Bone 

The  lacrimal  bone  is  irregularly  quadrilateral  in  shape 
and  is  very  thin.  It  is  situated  in  the  inner  wall  of  the 
orbit  between  the  nasal  process  of  the  superior  maxilla 
and  the  lateral  mass  of  the  ethmoid.  Below,  it  articulates 
with  the  inferior  turbinated  bone.  It  has  an  external  or 
orbital  surface  and  an  internal  or  nasal  surface.     The 


30   SUKGICAL  ANATOMY  OF  THE  MOUTH 

anterior  part  of  the  external  surface  is  grooved  for  the 

lacrimal  sac,  and  this  part  prolonged  downward  forms 
part  of  the  nasal  duct.  Superiorly  the  internal  surface 
closes  some  of  the  anterior  ethmoid  cells;  interiorly  it 
forms  part  of  the  outer  wall  of  the  nose. 

The  Nasal  Bone 

The  nasal  bones  are  two  four-sided  bones  which  meet 
in  the  median  line  forming  the  bridge  of  the  nose.  The 
upper  border  articulates  with  the  frontal  bone.  The  ex- 
ternal border  is  the  longest  and  articulates  with  the 
nasal  process  of  the  superior  maxilla.  The  internal 
border  meets  its  fellow  of  the  opposite  side;  posteriorly 
the  two  bones  form  a  crest  which  rests  upon  the  nasal 
spine  of  the  frontal  bone,  the  vertical  plate  of  the  eth- 
moid, and  the  cartilaginous  septum.  The  facial  surface 
is  concave  from  above  downward  at  its  upper  part,  and 
convex  below.  The  nasal  surface  for  the  most  part  is 
concave  except  where  it  articulates  with  the  nasal  proc- 
ess of  the  frontal  bone. 

The  Vomer 

The  vomer  is  a  thin,  flat  plate  of  bone  which  forms  the 
posterior  inferior  portion  of  the  bony  septum  of  the 
nose.  Its  upper  part  is  spread  out  into  two  wings  which 
articulate  with  the  rostrum  of  the  sphenoid.  The  ros- 
trum passes  between  the  two  wings,  while  the  vaginal 
processes  of  the  sphenoid  and  the  sphenoidal  processes 
of  the  palate  are  applied  to  the  margin.  The  anterior 
margin  of  the  vomer  articulates  with  the  cartilaginous 
septum  below,  and  above  with  the  perpendicular  plate 
of  the  ethmoid.  The  anterior  edge  fits  into  the  incisor 
crest  of  the  superior  maxilla.  The  inferior  edge  articu- 
lates with  the  nasal  crest  of  the  maxillary  and  palate 
bones.  The  posterior  border,  thin,  smooth  and  free, 
separates  the  posterior  nares. 


BONES  OF  THE  FACE 
The  Lower  Jaw 


31 


The  inferior  maxillary  bone  or  lower  jaw  consists  of  a 
body  and  two  ascending  branches  or  rami.  The  upper 
end  of  each  ramus  is  composed  of  two  processes,  an  an- 
terior pointed  coronoid  process  and  a  posterior,  round, 
articular  condyloid  process. 


Fig.  15 


Fig.  16 


Fig.  17 
Figs.  15,  16,  17. — Bones  of  the  Lower  Jaw.     (Cryer.) 

The  body  is  U-shape,  and  from  the  extremities  of  the 
U  the  rami  pass  upwards.  The  inferior  margin  is  called 
the  base,  the  superior  the  alveolar  process.  The  latter 
contains  the  alveoli  for  the  lower  teeth.  Anteriorly  the 
middle  of  the  body  exhibits  the  mental  protuberance,  on 
either  side  of  which  is  a  tubercle  called  the  mental  tu- 
bercle. Above  and  to  the  outer  side  of  the  mental  tu- 
bercle is  situated  the  mental  foramen.  Passing  down- 
ward and  forward  from  the  anterior  margin  of  the  ramus 
to  the  mental  foramen  is  the  external  oblique  line. 


32      SURGICAL  ANATOMY  OF  THE  MOUTH 

The  Internal  Surface.  — On  either  side  of  the  median 
line  is  the  digastric  fossa,  so  named  because  of  the  digas- 
tric muscle  being  inserted  at  this  point.  Above  the  di- 
gastric fossae  are  the  mental  tubercles  or  spines,  usually 
paired,  for  the  origin  of  the  geniohyoid  and  geniohyo- 
glossus  muscles.  Above  and  to  the  outer  side  of  the 
mental  spine  on  either  side  is  the  sublingual  fossa,  which 
lodges  the  sublingual  gland.  Between  the  digastric  and 
sublingual  fossae  is  the  mylohyoid  ridge  which  passes 
backward  and  upward  and  gives  origin  to  the  mylohyoid 
muscles. 

Each  ramus  has  an  external  surface,  an  internal  sur- 
face, a  condyle  and  a  coronoid  process.  The  external 
surface  is  flat  and  here  is  inserted  the  masseter  muscle. 
About  the  middle  of  the  internal  surface  is  the  inferior 
dental  foramen,  the  opening  of  the  inferior  dental  canal, 
which  transmits  the  inferior  vessels  and  nerves.  A  plate 
of  bone,  the  lingula,  overhangs  the  anterior  margin  of 
the  foramen.  The  posterior  border  of  the  ramus  meet- 
ing the  inferior  border  of  the  body,  forms  the  angle  of 
the  jaw.  Above,  the  posterior  border  terminates  in  a 
condyle.  The  head  of  the  condyle  is  separated  from  the 
base  by  a  constriction  called  the  neck.  The  articular  sur- 
face is  ellipsoidal  with  the  long  axis  nearly  transverse. 
On  the  anterior  surface  of  the  neck  is  the  pterygoid  de- 
pression for  the  insertion  of  the  external  pterygoid 
muscle.  The  anterior  border  of  the  ramus  terminates 
above  in  the  sharp  coronoid  process  for  the  insertion 
of  the  temporal  muscle.  The  condyle  and  the  coronoid 
process  are  separated  by  a  deep  excavation,  the  sigmoid 
notch. 

THE  SKULL 

The  bones  of  the  skull,  with  the  exception  of  those  of 
the  lower  jaw,  are  fitted  together  by  uneven  edges  with 
a  little  fibrous  tissue  interposed;  this  uneven  line  of  ar- 


THE  SKULL  33 

ticulation  is  called  a  suture.  There  are  two  exceptions 
to  this :  at  the  base  of  the  skull  the  basilar  process  of 
the  occipital  bone  is  united  to  the  body  of  the  sphenoid, 
and  the  jugular  process  of  the  occipital  is  united  to  the 
petrous  portion  of  the  temporal  by  a  layer  of  cartilage. 
Sutures  derive  their  names  from  the  bones  between  which 
they  lie ;  i.e.,  parieto-occipital,  etc.  Those  about  the  parie- 
tal bones  receive  special  names;  that  between  the  two 
parietal  bones  is  called  sagittal ;  that  posteriorly  between 
the  parietal  bones  and  the  occipital  is  called  the  lamb- 
doid;  anteriorly  between  the  parietals  and  the  frontal 
is  the  coronal  suture;  inferiorly  is  the  temporoparietal 
and  at  the  anterior  inferior  angle  is  the  sphenoparietal. 
Interposed  between  the  cranial  bones  we  often  find 
small  isolated  irregular  bones  called  wormian  bones. 
These  are  most  frequently  found  in  the  lambdoid  suture 
and  should  not  be  mistaken  for  fractures. 

Outer  Surface  of  the  Skull 

The  outer  surface  of  the  skull  is  divided  into:  (a)  an 
anterior;  (b)  superior;  (c)  lateral,  and  (d)  an  inferior 
or  basal  region. 

(a)  Anterior  Region.— The  anterior  region  presents  the 
openings  for  the  orbits  between  which  is  the  bridge  of  the 
nose,  formed  largely  by  the  nasal  bones.  Below  the  nasal 
bones  are  the  anterior  nasal  apertures  separated  by  the 
bony  septum.  Below  on  either  side  are  the  incisor  fossae, 
external  to  which  are  the  canine  fossae.  The  inferior 
maxilla  completes  the  facial  skeleton.  The  foramina  in 
this  region  are  the  supra-orbital,  infra-orbital,  mental 
and  malar. 

The  orbits  are  pyramidal  in  shape  with  the  base  for- 
ward. The  inner  walls  are  parallel,  while  the  outer  walls 
diverge.  Seven  bones  enter  into  the  formation  of  each 
orbit,  eleven  into  both,  four  bones  being  common  to  each. 
The  sphenoidal  fissure  (foramen  lacerum  anterius)  at  its 


34      SURGICAL  ANATOMY  OF  TflF  MOUTH 


Fig.  18. — A,  Supra-orbitat.  Foramen; 
B,  Infra-orbital  Foramen;  C,  Men- 
tal Foramen.     (Campbell.) 


terior  and  posterior  ethmoidal 
anteriorly  is  the  supra- 
orbital  notch    or    fora- 
men. 

(b)  Superior  Region. 
— The  superior  region 
extends  from  the  supra- 
orbital margin  to  the 
superior  curved  line  of 
the  occipital  bone.  It  is 
limited  laterally  by  the 
temporal  line.  It  is 
smooth,  convex  and 
ovoid  in  shape,  being 
broader  in  the  parietal 
than  in  the  frontal  re- 


inner  end  occupies  the 
apex  of  the  orbit,  while 
the  outer  part  lies  be- 
tween the  external  wall 
and  the  roof.  The  optic 
foramen  is  internal  and 
above  the  sphenoidal  fis- 
sure. Passing  forward 
to  the  floor  of  the  orbit 
is  the  infra-orbital  canal, 
which  terminates  at  the 
infra-orbital  foramen.  On 
the  inner  wall  anteriorly 
is  the  lacrimal  groove 
leading  into  the  nasal 
duct  or  tear  duct. 

Further  back  on  the 
inner  wall  are  the  an- 
foramina.     On  the  roof 


snon. 


(c)  Lateral  Region. — 
The  lateral  region  ex- 


Fig.  19. — Line  op  Supra-orbital,  Infra- 
orbital, and  Mental  Foramina. 
(Campbell.) 


THE  SKULL  35 

hibits  from  behind  forward  the  mastoid  process,  external 
auditory  meatus,  glenoid  fossa,  with  the  condyle  of  the 
lower  jaw,  the  zygoma ;  and,  internal  to  the  latter,  the 
coronoid  process  of  the  lower  jaw.  Above  the  zygoma  is 
the  temporal  fossa;  below  is  the  zygomatic  fossa.  The 
temporal  fossa  is  occupied  by  the  temporal  muscle  and  is 
bounded  above  by  the  temporal  crest  of  the  frontal  bone, 
and  the  lower  temporal  line  of  the  parietal;  the  latter 
curves  downward  to  join  the  supramastoid  crest  of  the 
temporal  bone,  which  is  continued  along  the  zygoma. 
Along  the  above  line  is  attached  the  temporal  fascia  which 
covers  the  temporal  muscle ;  the  zygomatic  fossa  is  partly 
covered  by  the  ramus  of  the  lower  jaw,  being  separated 
from  the  temporal  fossa  by  the  infratemporal  crest  and 
the  greater  wing  of  the  sphenoid.  The  foramina  opening 
into  this  fossa  are  the  foramen  ovale,  spinosum  and  pos- 
terior dental,  together  with  the  pterygomaxillary  and 
sphenomaxillary  fissures.  The  sphenomaxillary  fossa  is 
the  space  which  lies  in  the  angle  between  the  pterygo- 
maxillary and  sphenomaxillary  fissures.  Five  foramina 
open  into  this  space :  the  foramen  rotundum,  vidian  canal, 
pterygopalatine  canal,  sphenopalatine  foramen,  and  the 
posterior  palatine  canal.  Both  the  zygomatic  and  the 
sphenomaxillary  fossae  should  be  examined  carefully  on 
the  skull,  as  any  description  is  long  and  difficult  to  follow. 
(See  Gray  and  Cunningham.) 

(d)  The  Inferior  or  Basilar  Region.— The  lower  jaw 
should  be  removed,  and  it  will  then  be  seen  that  this 
region  is  naturally  divided  into  an  anterior,  middle,  and 
posterior  portion. 

Anterior  Division. — The  anterior  division  consists  of 
the  hard  palate  and  the  alveolar  arch.  In  front  in  the 
median  line  is  the  anterior  palatine  fossa  opening  into 
which  are  four  foramina,  the  foramina  of  Scarpa  and 
Stenson.  Posteriorly  on  either  side  is  the  posterior  pal- 
atine canal  for  the  larger  palatine  vessels  and  nerve. 

Middle  Division. — The  middle  division  extends  from 


:;<;    surgical  anatomy  of  tiil  mouth 

the  edge  of  the  hard  palate  to  the  foramen  magnum.  In 
the  median  line  is  the  basilar  process  and  the  body  of  the 
sphenoid,  on  either  side  of  which  is  the  petrous  portion 
of  the  temporal  bone.  Between  the  petrous  and  squa- 
mous portions  is  a  part  of  the  greater  wing  of  the  sphe- 
noid. In  the  anterior  part  of  this  region  are  the  openings 
of  the  posterior  nares  and  external  to  these  are  the  ptery- 
goid fossae.  In  the  angle  between  the  petrous  and 
squamous  portions  of  the  temporal  bone  is  seen  the  open- 
ing of  the  eustachian  tube.  Between  the  apex  of  the  pe- 
trous and  the  basilar  process  is  the  foramen  lacerum 
medium.  In  a  line  extending  outward  and  backward  from 
this  are  seen  the  lower  opening  of  the  carotid  canal,  the 
vaginal  and  styloid  processes  and  the  stylomastoid  fora- 
men. Somewhat  internal  to  these  are  the  foramen  lacerum 
posterius  or  jugular  and  the  internal  condylar  foramen. 
Posterior  Division. — On  each  side  of  the  foramen  mag- 
num are  the  condyles  of  the  occipital  bone,  the  under  sur- 
face of  the  jugular  process,  digastric  fossae,  occipital 
groove  and  mastoid  process. 

The  Interior  of  the  Skull 

The  internal  surface  of  the  base  of  the  skull  is  exposed 
by  sawing  horizontally  through  the  cranium  and  remov- 
ing the  vault  or  calvarium.  Three  fossae  may  then  be 
recognized:  (a)  anterior;  (b)  middle;  (c)  posterior. 

(a)  Anterior  Fossa.— The  anterior  fossa  is  convex  lat- 
erally and  in  the  median  portion  presents  a  depression. 
It  is  made  up  by  the  orbital  plates  of  the  frontal  bone,  the 
cribriform  plate  of  the  ethmoid  and  the  lesser  wings  with 
part  of  the  body  of  the  sphenoid.  Anteriorly  in  the  me- 
dian line  is  the  crista  galli  with  the  foramen  cecum 
immediately  in  front  of  it.  This  latter  sometimes  con- 
veys a  small  vein  from  the  nose  to  the  superior  longitu- 
dinal sinus.  On  either  side  of  the  crista  galli  are  the 
openings  of  the  cribriform  plate  which  are  occupied  by 


THE  SKULL  37 

filaments  of  the  olfactory  nerve,  and  here  also  is  the 
aperture  for  the  nasal  nerve. 

(b)  Middle  Fossa. — The  middle  fossa  consists  of  a  cen- 
tral and  two  lateral  portions.  The  central  part  is  formed 
by  the  olivary  eminence  and  the  sella  turcica.  The  latter 
portions  are  made  up  by  the  greater  wings  of  the  sphe- 
noid, the  squamous  and  the  anterior  surface  of  the  pe- 
trous portion  of  the  temporal.  The  foramina  seen  in  this 
fossa  are  the  optic,  through  which  passes  the  ophthalmic 
artery  and  the  optic  nerve ;  the  sphenoidal  fissure  which 
transmits  the  third,  fourth,  ophthalmic  division  of  the 
fifth,  the  sixth  nerve  and  the  ophthalmic  vein ;  the  fora- 
men rotundum,  which  gives  passage  to  the  second  divi- 
sion of  the  fifth;  the  foramen  ovale,  which  gives  exit  to 
the  third  division  of  the  fifth ;  while  through  the  foramen 
spinosum  the  middle  meningeal  artery  enters  the  skull. 
There  is  also  an  irregular  aperture,  the  foramen  lacerum 
medium,  between  the  apex  of  the  petrous  and  the  body 
of  the  sphenoid.  In  life  this  is  closed  by  fibrous  tissue. 
On  its  external  aspect  the  opening  of  the  carotid  canal 
for  the  carotid  artery  is  seen.  Anteriorly  is  the  vidian 
canal,  through  which  the  large  superficial  petrosal  nerve 
leaves  the  skull. 

(c)  Posterior  Fossa.— The  posterior  fossa  lodges  the 
cerebellum,  medulla  and  pons.  It  extends  from  the  su- 
perior border  of  the  petrous  to  the  internal  occipital  pro- 
tuberance. The  lateral  boundaries  are  the  grooves  for 
the  lateral  sinuses.  The  occipital,  the  petrous  and  mas- 
toid portions  of  the  temporal,  the  posterior  part  of  the 
parietal  and  the  body  of  the  sphenoid  take  part  in  its 
formation.  The  foramina  in  this  fossa  are  the  foramen 
magnum,  anterior  and  posterior  condylar  foramina,  the 
internal  auditory  meatus,  the  jugular  and  mastoid  fora- 
mina. All  these  foramina  are  paired  except  the  foramen 
magnum.  The  foramen  magnum  is  occupied  by  the  me- 
dulla oblongata,  the  vertebral  arteries,  and  the  spinal 
portion  of  the  spinal  accessory  nerve.     The  facial  and 


38      SURGICAL  ANATOMY  OF  THE  MOUTH 

auditory  nerves  leave  the  skull  through  the  internal  audi- 
tory meatus.  The  posterior  condylar  and  mastoid  fora- 
mina are  occupied  by  emissary  veins.  Through  the  jugu- 
lar foramen  (foramen  lacerum  posterius)  pass  the  lateral 
and  inferior  petrosal  sinuses,  the  glossopharyngeal,  spi- 
nal accessory,  and  the  pneumogastric  nerves. 

The  Calvaria.— The  upper  part  of  the  cranial  cavity  or 
calvaria  is  a  vaulted  dome  formed  by  the  frontal,  parietal 
and  occipital  bones ;  the  median  part  of  the  internal  sur- 
face is  grooved  for  the  superior  longitudinal  sinus.  It 
also  presents  shallow  cerebral  impressions,  small  grooves 
for  meningeal  vessels  and  depressions  for  the  pacchio- 
nian bodies. 

The  internal  surface  of  the  skull  is  marked  by  grooves 
for  blood  vessels.  The  most  important  of  these  are  the 
grooves  for  the  middle  meningeal  arteries,  the  internal 
carotid  arteries,  the  superior  longitudinal  sinus,  the  lat- 
eral sinuses,  and  the  superior  and  inferior  petrosal  si- 
nuses. 

The  Nasal  Fossae 

The  nasal  cavity  is  divided  into  two  nasal  fossae 
by  the  nasal  septum,  and  nine  of  the  bones  of  the  skull 
take  part  in  its  formation.  Each  fossa  has  a  floor,  a 
roof,  an  internal  and  an  external  wall.  The  floor  is 
formed  by  the  hard  palate :  the  median  wall  is  the  bony 
septum  of  the  nose,  which  consists  of  the  perpendicular 
plate  of  the  ethmoid  and  the  vomer.  The  roof  is  made 
up  of  the  nasal  bones,  the  nasal  portions  of  the  frontal 
bone,  the  cribriform  plate  of  the  ethmoid  and  the  body  of 
the  sphenoid.  The  external  wall  exhibits  the  three  tur- 
binated bones.  The  superior  and  middle  turbinates  are 
processes  of  the  ethmoid,  but  the  inferior  is  an  indepen- 
dent bone.  These  three  turbinated  bones  divide  the  ex- 
ternal wall  into  three  canals;  the  superior  meatus  be- 
tween the  superior  and  middle  turbinates;  the  middle 
meatus  between  the  middle  and  inferior  turbinates ;  the 


THE  JSKULL  39 

inferior  meatus  between  the  inferior  turbinate  and  the 
floor  of  the  nose.  The  external  wall  is  formed  by  the 
following  bones:  the  ethmoid;  the  nasal  surface  of  the 
nasal  process  of  the  maxilla,  and  the  nasal  surface  of 
the  body  of  the  same  bone ;  the  vertical  plate  of  the  pal- 
ate; the  inferior  turbinate  and  the  inner  surface  of  the 
lacrimal  bone. 

There  are  numerous  openings  leading  into  each  nasal 
cavity:  (a)  the  foramina  of  the  cribriform  plate;  (b)  the 
superior  orifice  of  the  incisive  canal;  (c)  the  inferior 
orifice  of  the  nasal  duct  which  opens  into  the  inferior 
meatus  under  the  inferior  turbinate;  (d)  the  hiatus  semi- 
lunaris, the  opening  of  the  antrum  of  Highmore;  (e)  the 
openings  of  the  ethmoidal  cells;  (/)  the  orifice  of  the 
sphenoidal  sinus  and  the  sphenopalatine  foramen;  (rj) 
the  opening  of  the  infundibulum,  which  leads  into  the 
anterior  ethmoidal  cells  and  the  frontal  sinus. 

The  following  air  sinuses  communicate  with  the  nasal 
fossae:  (a)  the  antrum  of  Highmore;  (b)  the  frontal 
sinus;  (c)  the  sphenoidal  sinus;  (d)  the  ethmoidal  si- 
nuses. These  sinuses  are  hollows  within  the  superior 
maxilla,  the  frontal,  the  sphenoid,  and  the  ethmoid  bones 
respectively. 

The  Temporomaxillary  Articulation 

This  articulation  is  the  joint  between  the  condyle  of 
the  lower  jaw  and  the  glenoid  fossa  of  the  temporal  bone. 
It  is  divided  into  an  upper  and  a  lower  portion  by  an 
articular  cartilage  which  is  adherent  to  the  capsular  liga- 
ment. The  external  lateral  ligament  is  a  means  of  re- 
enforcing  the  capsular  ligament.  It  is  attached  above 
to  the  zygoma,  and  below  to  the  neck  of  the  condyle. 
The  internal  lateral  ligament  extends  from  the  spinous 
process  of  the  temporal  bone  to  the  angle  of  the  jaw 
and  the  posterior  border  of  the  ramus. 


40      SURGICAL  ANATOMY  OF  THE  MOUTH 

MUSCLES  OF  THE  HEAD 

The  muscles  of  the  head  are  divisible  into  the  superfi- 
cial muscles,  the  muscles  of  the  orbit,  and  the  muscles  of 
mastication. 

Superficial  Muscles 

The  superficial  group  comprises  the  muscles  of  the 
scalp,  face  and  the  platysma  myoides  of  the  neck. 

Platysma  Myoides.— The  platysma  myoides  arises  from 
the  deep  fascia  over  the  pectoralis  major  muscle  and  is 
inserted  into  the  lower  border  of  the  inferior  maxilla,  into 
the  skin  of  the  lower  part  of  the  face,  blending  with  the 
muscles  about  the  angle  and  lower  part  of  the  mouth. 

Muscles  of  Scalp.  —  The  muscles  of  the  scalp  include  the 
muscles  of  the  external  ear  and  the  occipitofrontalis. 
The  ear  muscles  are  rudimentary  and  unimportant.  The 
occipitofrontalis  muscle  consists  of  two  muscular  slips 
separated  by  a  thin  intervening  aponeurosis.  The  pos- 
terior belly  arises  from  the  outer  two-thirds  of  the  supe- 
rior curved  line  of  the  occipital  bone.  This  portion  is 
called  the  occipitalis.  The  anterior  belly  has  no  attach- 
ments to  bone.  It  arises  from  the  epicranial  aponeurosis 
about  the  level  of  the  coronal  suture.  Over  the  supra- 
orbital arch  its  fibers  blend  with  the  corrugator  supercilii 
and  the  orbicularis  palpebrarum.  The  aponeurosis  cov- 
ers the  vertex  of  the  skull,  being  continuous  with  the 
aponeurosis  of  the  opposite  muscle  across  the  median 
line.    This  muscle  is  supplied  by  the  facial  nerve. 

Muscles  of  Face.— The  muscles  of  the  face  are  divided 
into  the  muscles  of  the  eye,  nose  and  mouth.  For  the 
most  part  these  muscles  are  small  and  difficult  to  dem- 
onstrate except  in  a  very  favorable  subject.  Only  the 
most  important  of  these  muscles  will  be  considered. 

Muscles  of  the  Eyelids. — The  muscles  of  the  eyelids 
include  the  orbicularis  palpebrarum,  the  tensor  tarsi,  the 


MUSCLES  OF  THE  HEAD  41 

corrugator  supercilii  and  the  levator  palpebrae  supe- 
riors. The  latter  muscle  is  described  under  the  orbital 
muscles. 

The  orbicularis  palpebrarum  is  a  sphincter  muscle  sur- 
rounding* the  eyelids ;  it  is  divided  into  an  external  and 
an  internal  portion.  At  the  inner  canthus  of  the  eye  it 
is  attached  to  the  tarsal  ligament.  Externally  this  muscle 
has  no  bony  attachments.  The  other  muscles  are  unim- 
portant. 

Muscles  of  the  Nose. — The  muscles  of  the  nose  are 
small,  feeble  and  unimportant. 

Muscles  of  the  Mouth. — The  muscles  of  the  mouth 
are  the  levator  labii  superioris  alaequae  nasi,  levator 
labii  superioris,  levator  anguli  oris,  zygomaticus  major 
and  minor,  the  risorius,  orbicularis  oris,  depressor  an- 
guli oris,  the  depressor  labii  inferioris,  levator  menti  and 
the  buccinator. 

The  orbicularis  oris  is  the  sphincter  muscle  of  the 
mouth  and  lies  between  the  skin  and  the  mucous  mem- 
brane of  the  mouth.-  It  is  attached  above  to  the  septum 
of  the  nose  and  the  incisor  fossa;  below  it  is  attached  to 
the  lower  jaw  on  each  side  of  the  symphysis.  From  these 
points  of  attachment  the  fibers  pass  outward  to  join  the 
rest  of  the  muscle,  which  is  formed  by  the  fibers  coming 
from  the  levator,  depressors,  and  the  buccinators. 

The  buccinator  muscle  arises  from  the  alveolar  arches 
of  the  upper  and  lower  jaw  and  from  the  pterygomaxil- 
lary  ligament.  The  fibers  pass  forward  to  the  angle  of 
the  mouth  where  they  join  the  levators  and  depressors. 
At  the  angle  of  the  mouth  the  central  fibers  decussate, 
those  from  below  being  continuous  with  the  upper  por- 
tion of  the  orbicularis  oris  and  those  from  above  with 
the  inferior  portion.  The  highest  and  lowest  fibers  pass 
into  the  orbicularis  oris  without  decussation. 

The  zygomaticus  major  arises  from  the  malar  portion 
of  the  zygoma.  The  fibers  pass  downward  to  be  inserted 
into  the  skin  and  the  orbicularis  oris. 


42   SURGICAL  ANATOMY  OF  THE  MOUTH 

The  zygomaticus  minor  .-irises  from  the  malar  bone 
and  is  inserted  into  the  orbicularis  oris. 

The  remaining  muscles  of  this  group  are  small  and 
unimportant. 

Muscles  of  the  Orbit 

The  muscles  of  the  orbit  are  seven  in  number.  One 
of  these,  the  levator  palpebrae  superioris,  belongs  to  the 
upper  eyelid,  while  the  remaining  six  are  muscles  of  the 
eyeball. 

The  levator  palpebrae  superioris  arises  from  the  mar- 
gin of  the  optic  foramen  above  the  origin  of  the  superior 
rectus.  It  is  inserted  into  the  upper  border  of  the  tarsal 
cartilage  and  slightly  into  the  orbicularis  palpebrarum. 

The  recti  muscles  are  four  in  number :  superior,  in- 
ferior, internal  and  external.  They  arise  from  a  mem- 
branous ring  surrounding  the  optic  foramen  which  is 
separated  into  two  parts;  the  superior  tendon  gives 
origin  to  the  superior  and  internal  recti,  and  the  upper 
head  of  the  external  rectus ;  the  inferior  common  tendon 
gives  origin  to  the  lower  head  of  the  external  rectus  to- 
gether with  the  internal  and  inferior  recti.  These  four 
muscle's  end  in  tendons  which  are  inserted  into  the  scle- 
rotic coat  of  the  eye. 

The  superior  oblique  arises  from  the  margin  of  the 
optic  foramen  between  the  superior  and  internal  recti.  It 
passes  forward  to  the  anterior  margin  of  the  orbit  where 
its  tendon  passes  through  a  fibrous  pulley  which  is  at- 
tached to  the  roof  of  the  orbit.  The  tendon  then  passes 
outward  and  is  inserted  into  the  sclerotic  coat  between 
the  superior  and  external  recti. 

The  inferior  oblique  arises  from  the  floor  of  the  orbit 
external  to  the  nasolacrimal  groove.  Its  tendon  passes 
outward  to  be  inserted  into  the  sclerotic  coat  between  the 
superior  and  external  recti. 

The  fourth  nerve  (trochlearis)  supplies  the  superior 
oblique;  the  sixth  (abducens)  supplies  the  external  rec- 


MUSCLES  OF  THE  HEAD 


43 


tus;  the  third  nerve  (motor  oculi)  supplies  the  others, — 
the  levator  palpebrae  superioris,  the  superior,  inferior, 
and  internal  recti,  and  the  inferior  oblique. 


Muscles  of  Mastication 

The  muscles  of  mastication  are  the  masseter,  temporal, 
external  and  internal  pterygoids  and  the  buccinator.  The 
buccinator  has  been  described. 

The  masseter  arises  from  the  lower  border  of  the  zy- 
goma in  its  anterior  two-thirds;  the  deep  part  of  the 


Fig.  20. — Masseter  Muscle.     (Campbell.) 

muscle  arises  from  the  inner  surface  of  the  whole  length 
of  the  zygoma.  It  is  inserted  into  the  outer  surface  of 
the  coronoid  process,  ramus,  and  angle  of  the  lower  jaw. 

The  temporal  muscle  arises  from  the  temporal  fossa 
and  the  temporal  fascia  which  covers  the  muscle.  It  is 
inserted  into  the  apex  and  inner  surface  of  the  coronoid 
process  of  the  lower  jaw. 

The  external  pterygoid  muscle  arises  by  two  heads. 
The  upper  head  is  attached  to  the  under  surface  of  the 


44   SUEGICAL  ANATOMY  OF  THE  MOUTH 

greater  wing  of  the  sphenoid  ;  the  lower  head  arises  from 
the  outer  surface  of  the  external  pterygoid  plate.  It  is 
inserted  into  the  front  of  the  neck  of  the  lower  jaw. 

The  internal  pterygoid  muscle  arises  by  two  heads. 
One  head  arises  from  the  inner  surface  of  the  external 


Fig.  21. — Temporal  Muscle.     (Gerrish.) 


pterygoid  plate  and  the  tuberosity  of  the  palate  bone; 
the  other  head  is  attached  to  the  tuberosity  of  the  upper 
jaw.  It  is  inserted  into  the  lower  part  of  the  inner  sur- 
face of  the  ramus  and  angle  of  the  lower  jaw. 

The  buccinator  is  supplied  by  the  facial  nerve.     The 


MUSCLES  OF  THE  NECK 


45 


Fig.  22. — Pterygoid  Muscles.     (Gerrish.) 

remaining  muscles  are  supplied  by  the  inferior  maxillary 
division  of  the  fifth  nerve. 


MUSCLES  OF  THE  NECK 


The  muscles  of  the  neck  are  the  following:  (a)  sterno- 
cleidomastoid; (b)  the  muscles  of  the  hyoid  bone;  (c)  the 
muscles  of  the  tongue;  (d)  the  muscles  of  the  pharynx 
and  soft  palate;  (e)  the  prevertebral  muscles. 

Sternocleidomastoid.— The  sternocleidomastoid  muscle 
arises  from  the  anterior  surface  of  the  manubrium  and 
the  inner  third  of  the  upper  surface  of  the  clavicle.  The 
muscle  is  inserted  into  the  outer  surface  of  the  mastoid 
process  of  the  temporal  bone,  and  into  the  superior 
curved  line  of  the  occipital  bone. 


46      SURGICAL  ANATOMY  OF  THE  MOUTH 

Muscles  of  the  Hyoid  Bone 

The  infrahyoid  muscles  connect  the  hyoid  bone  to  the 
scapula,  thorax,  and  thyroid  cartilage.  They  are  the 
omohyoid,  sternohyoid,  sternothyroid,  and  thyrohyoid. 

The  omohyoid  consists  of  two  fleshy  bellies  united  by  a 
central  tendon.  The  posterior  belly  arises  from  the  up- 
per border  of  the  scapula  and  from  the  transverse  liga- 
ment which  bridges  over  the  suprascapular  notch.  It 
passes  upward  and  forward  to  the  central  tendon.  From 
this  tendon  the  anterior  belly  proceeds  upward  to  be  in- 
serted into  the  lower  border  of  the  hyoid  bone. 

The  sternohyoid  muscle  arises  from  the  clavicle,  the 
first  costal  cartilage,  and  from  the  posterior  surface  of 
the  manubrium.  It  is  inserted  into  the  lower  border  of 
the  body  of  the  hyoid  bone. 

The  sternothyroid  muscle  arises  from  the  first  costal 
cartilage  and  the  posterior  surface  of  the  manubrium. 
It  passes  upward  in  front  of  the  trachea  beneath  the 
preceding  muscle,  to  be  inserted  into  the  oblique  line  of 
the  thyroid  cartilage. 

The  thyrohyoid  muscle  lies  in  the  same  plane  with  the 
preceding  muscle.  It  arises  from  the  oblique  line  of 
the  thyroid  cartilage,  and  passing  over  the  thyrohyoid 
membrane,  is  inserted  into  the  body  and  greater  cornu 
of  the  hyoid  bone. 

The  suprahyoid  muscles  connect  the  hyoid  bone  to  the 
lower  jaw,  cranium  and  tongue.  They  comprise  the  di- 
gastric, stylohyoid,  mylohyoid  and  geniohyoid  muscles. 

The  digastric  muscles  consist  of  two  fleshy  bellies 
united  by  a  central  tendon.  The  posterior  belly  arises 
from  the  digastric  groove  on  the  inner  side  of  the  mas- 
toid. It  passes  downward  and  forward  to  the  central 
tendon  which  is  attached  to  the  hyoid  bone  by  a  pulley* 
like  band  of  fascia.  The  anterior  belly  of  the  muscle 
passes  upward  from  the  central  tendon,  to  be  inserted 


MUSCLES  OF  THE  NECK  47 

into  a  depression  on  the  lower  border  of  the  jaw  near  the 
symphysis. 

The  stylohyoid  muscle  arises  from  the  styloid  process 
of  the  temporal  bone,  and  is  inserted  into  the  body  of 
the  hyoid  bone.  This  muscle  is  usually  pierced  by  the 
tendon  of  the  digastric  muscle. 

The  mylohyoid  muscle  arises  from  the  lower  three- 
fourths  of  the  mylohyoid  ridge  of  the  lower  jaw.  It  is 
inserted  into  the  upper  border  of  the  body  of  the  hyoid 
bone  and  into  a  median  raphe  which  extends  from  the 
hyoid  bone  to  the  chin.  This  muscle  forms  the  floor  of 
the  mouth.  The  geniohyoid  muscle  arises  from  the  in- 
ferior genial  tubercle  on  the  inner  side  of  the  symphysis 
of  the  lower  jaw,  and  is  inserted  into  the  body  of  the 
hyoid  bone.  This  muscle  is  concealed  by  the  mylohyoid 
muscle. 

Muscles  of  the  Tongue 

The  muscular  substance  of  the  tongue  consists  of  two 
series  of  muscles  on  either  side  of  a  median  raphe.  It  is 
composed  of  extrinsic  and  intrinsic  muscles. 

The  extrinsic  muscles  are  the  geniohyoglossus,  hyo- 
glossus,  styloglossus  and  palatoglossus. 

The  geniohyoglossus  muscle  arises  from  the  upper 
genial  tubercle  behind  the  symphysis  of  the  lower  jaw. 
The  muscle  is  fanshaped;  the  lowest  fibers  are  inserted 
into  the  body  of  the  hyoid;  the  highest  fibers  are  attached 
to  the  tip  of  the  tongue ;  and  the  intermediate  fibers  pass 
into  the  substance  of  the  tongue. 

The  hyoglossus  muscle  arises  from  the  body  and  the 
greater  cornu  of  the  hyoid  bone  and  is  inserted  into  the 
side  of  the  tongue. 

The  styloglossus  muscle  arises  from  the  styloid  proc- 
ess of  the  temporal  bone  and  is  inserted  into  the  side 
and  under  surface  of  the  tongue. 

The  palatoglossus  muscle  arises  from  the  under  sur- 
face of  the  soft  palate,  where  it  is  continuous  with  the 


48   SURGICAL  ANATOMY  OF  THE  MOUTH 

fibers  of  the  opposite  muscle.  It  is  inserted  into  the  side 
of  the  tongue,  blending  with  the  styloglossus. 

The  intrinsic  muscles,  which  lie  wholly  within  the  sub- 
stance of  the  tongue,  are  four  in  number  on  either  side. 

The  superior  lingualis  extends  from  the  base  to  the 
tip  of  the  tongue  on  the  dorsum. 

The  inferior  lingualis  occupies  the  under  surface  of  the 
tongue  between  the  geniohyoglossus  and  the  hyoglossus 
muscles.  The  transverse  fibers  radiate  outward  to  the 
dorsum  and  sides  of  the  tongue,  blending  with  the  ex- 
trinsic muscles.  The  vertical  fibers  arise  from  the  dor- 
sum of  the  tongue  and  pass  downward  and  outward  to  the 
sides  of  the  tongue,  blending  with  the  transverse  fibers. 

The  sternocleidomastoid  is  supplied  by  the  spinal  ac- 
cessory nerve  aiid  by  branches  of  the  cervical  plexus. 
The  omohyoid,  sternohyoid  and  sternothyroid  are  sup- 
plied by  the  loop  of  communication  between  the  descen- 
dens  and  communicans  hypoglossi  (non).  The  thyro- 
hyoid, geniohyoid,  geniohyoglossus,  styloglossus  and  the 
intrinsic  muscles  of  the  tongue  are  supplied  bjT  the  hypo- 
glossal nerve.  The  mylohyoid  muscle  is  supplied  by  the 
mylohyoid  branch  of  the  inferior  dental  nerve.  The  an- 
terior branch  (belly)  of  the  digastric  is  supplied  by  the 
mylohyoid  branch  of  the  inferior  dental,  and  the  poste- 
rior belly  is  supplied  by  the  facial  nerve.  The  facial 
nerve  also  supplies  the  stylohyoid  muscles. 

Muscles  of  the  Pharynx 

The  muscles  of  the  pharynx  are  the  stylopharyngeus, 
palatopharyngeus  and  the  three  constrictor  muscles. 

The  superior  constrictor  arises  from  the  lower  half  of 
the  posterior  border  of  the  internal  pterygoid  plate,  the 
pterygomaxillary  ligament  and  from  the  mylohyoid  ridge 
of  the  lower  jaw.  The  fibers  pass  backward  and  are  in- 
serted into  the  median  raphe.  The  highest  fibers  are  at- 
tached to  the  pharyngeal  spine  of  the  occipital  bone. 


MUSCLES  OF  THE  NECK  49 

The  middle  constrictor  muscle  arises  from  the  stylo- 
hyoid ligament  and  from  the  cornua  of  the  hyoid  bone. 
The  muscle  is  inserted  into  the  median  raphe. 

The  inferior  constrictor  muscle  arises  from  the  oblique 
line  of  the  thyroid  and  from  the  side  of  the  cricoid  cartil- 
age. Its  fibers  are  inserted  into  the  median  raphe  on 
the  back  of  the  pharynx.  The  lower  fibers  blend  with 
muscular  fibers  of  the  esophagus. 

The  stylopharyngeus  arises  from  the  styloid  process 
of  the  temporal  bone  and  enters  the  wrall  of  the  pharynx 
between  the  superior  and  middle  constrictors  of  the 
pharynx.  It  is  inserted  into  the  superior  and  posterior 
borders  of  the  thyroid  cartilage. 

The  palatopharyngeus  muscle  arises  from  the  soft  pal- 
ate by  two  bands.  The  posterior  fasciculus  joins  with  the 
opposite  muscle  in  the  median  line ;  the  anterior  fascicu- 
lus lies  in  the  soft  palate  and  joins  in  the  median  line  the 
muscle  of  the  opposite  side.  The  muscle  passes  down- 
ward behind  the  tonsil  and  is  inserted  with  the  stylo- 
pharyngeus into  the  posterior  border  of  the  thyroid  car- 
tilage. 

Muscles  of  the  Soft  Palate 

The  soft  palate  is  composed  of  five  pairs  of  muscles 
covered  by  mucous  membrane.  These  muscles  are  the 
palatopharyngeus,  azygos  uvulae,  levator  palati,  tensor 
palati  and  the  palatoglossus. 

The  palatopharyngeus  and  the  palatoglossus  muscles 
have  been  described. 

The  azygos  uvulae  muscle  consists  of  two  bundles 
of  fibers  lying  between  the  layers  of  the  palatopharyn- 
geus. They  arise  from  the  posterior  nasal  spine  and 
unite  as  they  pass  downward  to  end  in  the  uvula. 

The  levator  palati  has  two  origins.  One  portion  arises 
from  the  apex  of  the  petrous  portion  of  the  temporal 
bone ;  the  other  portion  arises  from  the  cartilaginous  eu- 
stachian tube.    It  enters  the  soft  palate  between  the  two 


50      SURGICAL  ANATOMY  OF  TIIK  MOUTH 

parts  of  the  palatopharyngeus  and  is  inserted  into  the 
aponeurosis  of  the  soft  palate. 

The  tensor  palati  arises  from  the  scaphoid  fossa  and 
from  the  cartilaginous  eustachian  tube.  The  muscle 
passes  downward  and  ends  in  a  tendon  which  hooks 
around  the  hamular  process  and  is  inserted  into  the 
aponeurosis  of  the  soft  palate  and  posterior  border  of  the 
hard  palate. 

The  constrictors  of  the  pharynx,  palatoglossus,  palato- 
pharyngeus, levator  palati  and  azygos  uvulae  are  inner- 
vated by  the  pharyngeal  plexus.  The  tensor  palati  is 
supplied  by  the  otic  ganglion.  The  glossopharyngeal 
nerve  supplies  the  stylopharyngeal  muscle,  while  the  in- 
ferior constrictor  receives  an  additional  supply  through 
the  external  and  inferior  laryngeal  nerves. 

Deep  Lateral  and  Prevertebral  Muscles  of  the  Neck 

These  muscles  are  divided  into  three  groups :  (a)  verte- 
brocostal; (b)  vertebrocranial ;  (c)  vertebral. 

The  vertebrocostal  muscles  are  the  scalenus  anticus, 
scalenus  medius  and  the  scalenus  posticus. 

The  scalenus  anticus  arises  from  the  anterior  tubercles 
of  the  transverse  processes  of  the  third,  fourth,  fifth,  and 
sixth  cervical  vertebrae.  It  is  inserted  into  the  scalene 
tubercle  on  the  first  rib. 

The  scalenus  medius  arises  from  the  posterior  tuber- 
cles of  the  transverse  processes  of  the  cervical  verte- 
brae, from  the  second  to  the  sixth  inclusive.  It  is  in- 
serted into  a  rough  area  on  the  first  rib  behind  the  groove 
for  the  subclavian  artery. 

The  principal  muscle  of  the  vertebral  group  is  the 
longus  colli.  These  muscles  are  of  no  practical  impor- 
tance. 

The  vertebrocranial  group  is  composed  of  the  rec- 
tus capitis  anticus  major,  minor,  and  lateralis  mus- 
cles. 


THE  SPINAL  COED  51 

THE  NERVOUS  SYSTEM 

The  nervous  system  consists  of  the  cerebrospinal  and 
the  sympathetic  systems. 

The  sympathetic  system  is  composed  of  a  series  of 
ganglia,  bound  together  by  intervening  cords,  placed  on 
each  side  of  the  spinal  column.  It  also  includes  various 
plexuses  of  nerves  and  several  scattered  ganglia.  It  is 
intimately  connected  with  the  cerebrospinal  system. 

The  cerebrospinal  system  consists  of  the  brain,  spinal 
cord  and  peripheral  nerves.  There  are  thirty-one  pairs 
of  spinal  nerves,  which  are  attached  to  the  spinal  cord  by 
an  anterior  and  a  posterior  root.  There  are  twelve  pairs 
of  cranial  nerves,  which  are  given  off  from  the  brain. 

The  Cerebrospinal  Nervous  System 

The  brain  and  spinal  cord  are  composed  of  two  sub- 
stances :  gray  substance,  which  is  composed  of  nerve  cells, 
and  white  substance,  which  is  composed  of  nerve  fibers. 
The  neuroglia,  which  is  a  connective  tissue  in  function, 
forms  the  bed  in  which  the  nerve  cells  lie.  It  is  present 
in  both  gray  and  white  matter. 

THE  SPINAL  CORD 

The  spinal  cord  is  that  part  of  the  cerebrospinal  sys- 
tem which  occupies  the  upper  two-thirds  of  the  spinal 
canal.  It  extends  from  the  foramen  magnum  to  the  level 
of  the  upper  border  of  the  second  lumbar  vertebra.  It 
is  about  forty-five  centimeters  in  length.  At  the  foramen 
magnum  the  spinal  cord  becomes  continuous  with  the 
medulla  oblongata,  while  below  it  terminates  in  a  pointed 
extremity  called  the  conus  medullaris.  From  the  end  of 
the  latter  a  slender  band  is  prolonged  downward  which 
is  called  the  filum  terminale. 


52      SURGICAL  ANATOMY  OF  THE  MOUTH 

The  cord  is  protected  by  three  membranes,  the  pia 
mater,  the  arachnoid  and  the  dura  mater.  The  pia  mater 
is  a  fibrous  membrane  containing  numerous  blood  ves- 
sels. It  is  closely  applied  to  the  cord,  and  septa  project 
from  the  pia  into  the  substance  of  the  cord. 

The  arachnoid  is  a  very  delicate  transparent  membrane 
immediately  external  to  the  pia.  For  practical  purposes 
it  may  be  regarded  as  a  part  of  the  pia  mater.  External 
to  the  arachnoid,  the  dura  mater  forms  a  sheath  which  is 
continuous  above  with  the  dura  mater  of  the  cranial  cav- 
ity. The  spinal  cord  is  suspended  in  this  sheath  by  two 
lateral  ligaments  called  the  ligamenta  denticulata. 

In  the  dorsal  region  the  cord  is  of  uniform  size  and 
circular  in  outline.  In  the  cervical  and  lumbar  regions 
it  increases  in  diameter.  The  cervical  enlargement  be- 
gins at  the  upper  end  of  the  cord  and  subsides  opposite 
the  second  dorsal  vertebra.  The  lumbar  enlargement 
begins  at  the  tenth  dorsal  and  tapers  away  into  the  conus 
medullaris. 

The  cord  is  divided  into  lateral  portions  by  an  anterior 
and  posterior  fissure.  They  are  known  respectively  as 
the  anterior  and  posterior  median  fissures.  The  anterior 
is  wider  but  shallower  than  the  posterior.  Where  they 
come  into  relation  near  the  center  of  the  cord,  between 
their  internal  extremities,  there  is  a  septum  known  as  the 
commissure. 

The  spinal  cord  is  composed  of  a  central  core  of  gray 
matter  surrounded  by  white  matter.  The  gray  matter  of 
the  cord  presents  the  appearance  of  the  letter  "H. "  The 
transverse  part  of  the  "H"  is  called  the  gray  commis- 
sure. The  parts  above  the  horizontal  line  are  called  the 
anterior  horns,  and  the  parts  below  are  the  posterior 
horns. 

The  shape  and  disposition  of  the  gray  matter  divide 
the  white  matter  into  an  anterior,  posterior  and  two  lat- 
eral masses  known  as  columns. 

The  posterior  column  is  wedge-shaped  and  lies  between 


THE  BRAIN  53 

the  posterior  fissure  and  the  posterior  horn  of  gray  mat- 
ter. The  lateral  column  occupies  the  space  between  the 
anterior  and  posterior  horns.  The  anterior  includes  the 
white  matter  between  the  anterior  fissure  and  the  anterior 
horn  of  gray  matter.  These  columns  are  subdivided  in 
the  different  regions  of  the  cord. 

A  description  of  the  different  fiber  tracts  is  not  possible 
without  illustrations. 

The  central  canal  of  the  spinal  cord  is  a  minute  tunnel 
found  in  the  gray  commissure.  Above,  it  passes  into  the 
medulla  oblongata,  and  below,  it  ends  blindly  in  the  filuni 
terminale. 

THE  BRAIN 

The  brain  is  the  upper  part  of  the  cerebrospinal  sys- 
tem. It  occupies  the  cavity  of  the  cranium  and  is  sur- 
rounded by  the  meninges,  the  dura,  pia  and  arachnoid. 

Dura  Mater. — The  dura  mater  is  a  dense  fibrous  mem- 
brane lining  the  interior  of  the  skull.  It  is  the  internal 
periosteum  of  the  skull,  and  is  one  of  the  coverings  of  the 
brain.  It  is  adherent  to  the  inner  surface  of  the  skull 
especially  opposite  the  sutures.  Four  processes  of  dura 
mater  are  sent  nrward  into  the  cavity  of  the  skull.  These 
are  the  falx  cerebri,  tentorium  cerebelli,  falx  cerebelli  and 
the  diaphragma  sellae. 

The  falx  cerebri  is  an  arched  process  of  the  dura  de- 
scending in  the  longitudinal  fissures  between  the  cerebral 
hemispheres.  In  front  it  is  attached  to  the  crista  galli 
and  behind  to  the  upper  surface  of  the  tentorium.  Su- 
periorly it  contains  the  superior  longitudinal  sinus  and  is 
attached  to  the  skull.    The  lower  margin  is  free. 

The  tentorium  cerebelli  covers  the  surface  of  the  cere- 
bellum and  supports  the  posterior  lobes  of  the  brain.  It 
is  attached  to  the  inner  surface  of  the  occipital  bone, 
enclosing  on  each  side  the  lateral  sinus.  In  front  it  is 
attached  to  the  upper  margin  of  the  petrous  portion  of 


54      SURGICAL  ANATOMY  OF  THE  MOUTH 

the  temporal  bone,  enclosing  the  superior  petrosal  sinus. 

The  falx  cerebelli  is  placed  between  the  lateral  lobes  of 
the  cerebellum.  It  is  attached  superiorly  to  the  tentorium 
and  posteriorly  to  the  internal  occipital  crest. 

The  diaphragma  sellae  forms  a  circular  fold  which 
makes  a  roof  for  the  sella  turcica. 

Arachnoid.— The  arachnoid  is  a  delicate  transparent 
membrane  which,  for  practical  purposes,  may  be  consid- 
ered a  part  of  the  pia  mater. 

Tia.  — The  pia  mater  is  a  vascular  membrane  consist- 
ing of  plexuses  of  blood  vessels  held  together  by  connec- 
tive tissue.  It  covers  the  surface  of  the  brain  and  is  pro- 
longed into  the  interior  as  the  velum  interpositum  and 
the  choroid  plexuses. 

Divisions  of  Brain 

The  brain  may  be  divided  into  the  cerebrum,  cerebel- 
lum, pons  Varolii  and  the  medulla  oblongata.  The  aver- 
age weight  of  the  male  brain  is  50  ounces  and  of  the 
female  45  ounces. 

Viewed  from  above  the  brain  is  oval,  with  the  greatest 
transverse  diameter  slightly  posterior  to  the  center. 
From  this  point  of  view  the  two  hemispheres  only  are 
visible,  separated  from  each  other  by  the  longitudinal  fis- 
sure. The  inferior  part  of  the  brain  is  called  the  base, 
and  is  adapted  to  the  base  of  the  skull.  Posteriorly  is 
seen  the  medulla,  which  is  continuous  with  the  spinal 
cord.  Above  and  behind  the  medulla  is  seen  the  cere- 
bellum, or  small  brain.  Above  and  anterior  to  the 
medulla  is  a  white  elevation  called  the  pons  Varolii. 

In  front  of  the  pons  is  a  hollow  which  is  bounded  lat- 
erally by  the  crura  cerebri,  which  disappear  by  passing 
into  the  cerebrum.  Passing  around  each  eras  on  either 
side  is  the  optic  tract.  The  two  tracts  join  together 
anteriorly  to  form  the  optic  chiasm.  Passing  forward 
from  the  optic  chiasm  is  the  optic  nerve  of  each  side. 


THE  BRAIN  55 

The  crura  cerebri,  the  optic  tracts  and  the  optic  chiasm 
enclose  the  interpeduncular  space.  Within  this  area  are 
seen  the  tuber  cinereum,  the  posterior  perforated  space 
and  the  corpora  mammillares. 

The  pons,  medulla  and  cerebellum  occupy  the  posterior 
fossa  of  the  skull,  being  separated  from  the  cerebrum  by 
the  tentorium  cerebelli.  They  surround  a  cavity  called 
the  fourth  ventricle. 

The  cerebrum  forms  the  larger  part  of  the  brain,  occu- 
pies the  anterior  and  middle  fossae  of  the  skull  and  is 
separated  from  the  cerebellum  by  the  tentorium  cerebelli. 
The  two  cerebral  hemispheres  are  separated  from  each 
other  by  the  longitudinal  fissure.  The  hemispheres  are 
connected  with  one  another  by  the  corpus  callosum,  a 
broad  transverse  band  seen  at  the  bottom  of  the  longi- 
tudinal fissure.  Each  hemisphere  has  a  cavity  in  its  cen- 
ter called  the  lateral  ventricle  of  the  brain.  Below  the 
cerebral  hemispheres  is  the  interbrain,  which  is  composed 
largely  of  gray  matter  arranged  in  a  mass  on  either  side, 
called  the  optic  thalamus.  Between  the  optic  thalami  is 
a  narrow  cavity  called  the  third  ventricle.  The  third  ven- 
tricle is  connected  to  the  lateral  ventricles  by  two  small 
apertures  called  the  foramina  of  Munro. 

The  cerebrum  is  connected  with  the  pons,  medulla  and 
cerebellum  by  a  stalk  called  the  midbrain.  This  is  com- 
posed of  the  crura  cerebri,  the  corpora  quadrigemina  and 
the  superior  peduncles  of  the  cerebellum.  The  midbrain 
is  channeled  by  a  narrow  canal  called  the  aqueduct  of 
Sylvius,  which  extends  between  the  third  and  fourth  ven- 
tricles. 

The  Medulla  Oblongata 

The  medulla  oblongata,  or  bulb,  is  continuous  with  the 
spinal  cord.  It  is  about  an  inch  in  length  and  ends  at  the 
lower  border  of  the  pons  Varolii.  Its  anterior  surface 
lies  behind  the  basilar  process  of  the  occipital  bone,  and 


56   SURGICAL  ANATOMY  OF  THE  MOUTH 

its  posterior  surface  lies  in  the  vallecula  of  the  cere- 
bellum. 

The  Fourth  Ventricle 

The  fourth  ventricle  is  a  cavity  in  the  pons  and  medulla 
oblongata,  being  anterior  to  the  cerebellum.  Below,  it  is 
continuous  with  the  central  canal  of  the  cord,  and  above, 
it  is  connected  to  the  third  ventricle  by  the  aqueduct  of 
Sylvius.  Its  floor  is  formed  by  the  dorsal  surfaces  of  the 
medulla  and  pons.  The  lateral  boundaries  are  formed 
by  the  peduncles  of  the  cerebellum.  The  roof  of  the 
fourth  ventricle  is  formed  from  above  downward  by  the 
superior  peduncles  of  the  cerebellum,  the  superior  medul- 
lary velum,  the  inferior  medullary  velum,  the  tela  cho- 
roidea  inferior,  the  obex  and  the  lingula.  The  cavity  of 
the  fourth  ventricle  communicates  with  the  subdural 
space  by  three  foramina  which  are  lodged  in  the  roof. 
The  median  foramen  is  called  the  foramen  of  Magendi 
and  the  lateral  foramina,  placed  on  either  side,  are  known 
as  the  foramina  of  Key  and  Retzius.  In  the  floor  of  the 
fourth  ventricle  are  found  the  nuclei  of  origin  of  the 
cranial  nerves  from  the  fifth  to  the  twelfth  inclusive.  In 
the  floor  of  the  aqueduct  of  Sylvius  are  the  nuclei  of  the 
third  and  fourth  nerves. 

The  Pons  Varolii 

The  pons  Varolii  consists  of  an  anterior  and  a  pos- 
terior portion.  The  anterior  part  contains  three  layers 
of  fibers,  superficial,  transverse,  and  longitudinal  fibers, 
with  a  large  amount  of  gray  matter,  the  nucleus  pontis, 
placed  between  the  intersecting  fibers. 

The  longitudinal  fibers  are  the  continuation  of  the 
pyramidal  tracts  of  the  medulla.  These  fibers  pass  into 
the  crura  cerebri. 

The  transverse  fibers  pass  from  side  to  side  and  con- 
stitute the  middle  peduncles  of  the  cerebellum. 


THE  BRAIN  57 

The  dorsal  part  of  the  pons  is  continuous  with  the 
reticular  formation  of  the  medulla  below  and  superiorly 
it  is  continuous  with  the  tegmentum  of  the  crura  cerebri. 
The  pons  contains  the  nuclei  of  the  fifth,  sixth,  seventh 
and  eighth  nerves  and  the  superior  olivary  nucleus. 

The  Cerebellum 

The  cerebellum  lies  behind  the  pons  and  medulla  and 
below  the  posterior  portion  of  the  cerebral  hemispheres. 
It  consists  of  gray  matter  on  the  surface  and  white  mat- 
ter interiorly.  Its  surface  is  traversed  by  fissures  called 
sulci,  which  give  it  a  foliated  or  laminated  appearance. 
The  cerebellum  is  divided  into  a  median  portion  called 
the  vermis,  and  two  lateral  parts  called  the  lateral  hemi- 
spheres. The  hemispheres  are  separated  behind  by  the 
posterior  notch  and  in  front  by  the  anterior  notch. 

The  largest  and  deepest  fissure  is  the  great  horizontal 
fissure,  which  begins  in  front  of  the  pons  and  passes 
around  the  free  margin  of  the  hemisphere  to  the  middle 
line  behind.  It  divides  the  cerebellum  into  an  upper  and 
lower  portion.  There  are  numerous  secondary  fissures 
dividing  the  cerebellum  into  lobes. 

The  cerebellum  is  connected  to  the  cerebrum,  pons  and 
medulla  by  three  pairs  of  peduncles  called  respectively 
the  superior,  middle  and  inferior  peduncles. 

The  gray  matter  of  the  cerebellum  occupies  the  surface, 
and  there  are  also  masses  of  it  in  the  interior. 

The  white  matter  of  the  cerebellum  is  called  the  medul- 
lary body. 

The  Cerebral  Hemispheres 

Lobes  of  the  Brain.  — Each  hemisphere  is  subdivided 
into  seven  lobes. 

The  frontal  lobe  is  bounded  by  the  longitudinal  fissure 
internally,  the  fissure  of  Sylvius  below,  and  behind,  by 
the  fissure  of  Rolando. 


58      SURGICAL  ANATOMY  OF  TIIK  MOUTH 

The  parietal  lobe  is  bounded  above  by  the  longitudinal 

fissure,  below  by  the  fissure  of  Sylvius,  in  front  by  the 
fissure  of  Rolando,  and  behind  by  the  parieto-occipital 
fissure. 

The  occipital  lobe  lies  behind  the  parieto-occipital  fis- 
sure. 

The  temporal  lobe  lies  below  the  fissure  of  Sylvius. 

The  island  of  Reil  lies  in  the  fissure  of  Sylvius  on  a 
deeper  plane  than  the  general  surface  of  the  hemisphere. 

The  limbic  lobe  is  seen  on  the  median  surface  of  the 
hemisphere  in  the  form  of  a  ringlike  convolution. 

The  olfactory  lobe  is  placed  on  the  under  surface  of 
the  frontal  lobe.  It  consists  of  the  olfactory  bulb  with 
its  roots  and  the  trigonum  olfactorium. 

The  surfaces  of  the  hemispheres  are  formed  of  con- 
volutions with  intervening  fissures,  which  arrangement 
enables  it  to  present  a  large  area  of  surface. 

Fissures  of  the  Brain.— The  principal  fissures  of  the 
hemispheres  are  the  following:  the  great  longitudinal  fis- 
sure separates  the  hemispheres  from  each  other,  extend- 
ing from  the  front  of  the  cerebrum  to  the  back.  The  floor 
of  this  fissure  is  formed  by  the  corpus  callosum,  a  com- 
missural band,  which  connects  the  two  hemispheres. 

The  fissure  of  Sylvius  is  the  most  conspicuous  fissure 
on  the  surface  of  the  hemisphere.  It  is  composed  of  a 
short  stem  from  the  outer  extremity  of  which  three 
branches  radiate.    It  lodges  the  middle  cerebral  artery. 

The  fissure  of  Rolando  passes  obliquely  across  the 
outer  surface  of  the  hemisphere,  intervening  between  the 
frontal  and  parietal  convolutions. 

The  parieto-occipital  fissure  is  situated  partly  on  the 
outer  surface  and  partly  on  the  internal  surface  of  the 
hemisphere.  The  outer  portion  is  about  half  an  inch 
long  and  is  limited  by  an  arching  convolution  which  winds 
around  its  extremity.  The  internal  portion  passes  down- 
ward on  the  internal  surface  and  terminates  behind  the 
corpus  callosum  in  the  calcarine  fissure. 


THE  BRAIN  59 

The  callosomarginal  fissure  is  situated  on  the  median 
surface  of  the  hemisphere.  It  divides  the  front  part  of 
the  median  surface  into  an  upper  marginal  and  a  lower 
callosal  convolution. 

The  calcarine  fissure  is  placed  on  the  median  surface 
of  the  hemisphere.  It  begins  close  to  the  posterior  ex- 
tremity of  the  hemisphere,  passes  forward  and  is  joined 
by  the  internal  parieto-occipital  fissure.  It  ends  behind 
the  posterior  extremity  of  the  corpus  callosum. 

The  collateral  fissure,  also  placed  on  the  median  sur- 
face, runs  forward  from  the  posterior  extremity  of  the 
brain  below  and  external  to  the  calcarine  fissure. 

The  hippocampal  fissure,  or  dentate  fissure,  begins 
behind  the  splenium  of  the  corpus  callosum  and  passes 
forward  between  the  gyrus  dentatus  and  the  hippocampal 
convolution. 

The  transverse  fissure  extends  from  the  foramen  of 
Munro  of  each  side  to  the  termination  of  the  descending 
horns  of  the  lateral  ventricles. 

Ventricles  of  the  Brain.— The  ventricles  of  the  brain 
are  five  in  number.  Two  lateral  ventricles  lie  within  the 
substance  of  the  hemispheres  and  are  connected  to  the 
third  ventricle  through  the  foramen  of  Munro.  The  third 
ventricle  is  placed  between  the  optic  thalami  and  the 
interbrain.  It  communicates  with  the  lateral  ventricles 
through  the  foramen  of  Munro,  and  with  the  fourth  ven- 
tricle by  the  aqueduct  of  Sylvius.  The  fourth  ventricle 
lias  been  described  under  the  medulla  oblongata.  The 
fifth  ventricle  is  situated  in  the  septum  lucidum,  between 
the  lateral  ventricles. 

Ganglia. — The  gray  matter  of  the  brain  is  disposed  in 
two  groups,  that  of  the  cortex  and  that  of  the  basal  gan- 
glia. 

The  gray  cortex  is  spread  over  the  entire  surface  of  the 
hemispheres,  but  is  not  equally  thick  in  all  localities. 

The  basal  ganglia  are  a  series  of  gray  masses  in  the 
base  of  each  hemisphere,  and  are  named  as  follows :  the 


GO   SURGICAL  ANATOMY  OF  THE  MOUTH 

corpus  striatum,  the  claustrum,  the  nucleus  amygdalae 
and  the  optic  thalamus.  The  latter  is  part  of  the  inter- 
brain. 

The  white  matter  of  the  brain  is  arranged  in  three 
groups:  the  peduncular  filters  connect  the  hemispheres 
with  the  medulla  and  cord;  the  commissural  fibers  con- 
nect the  two  hemispheres;  the  association  fibers  connect 
different  structures  in  the  same  hemisphere. 

The  Interbrain 

The  interbrain  is  the  region  of  the  third  ventricle.  It 
is  connected  superiorly  with  the  hemispheres  and  infe- 
riorly  with  the  midbrain.  Its  inferior  surface  corre- 
sponds with  the  interpeduncular  space.  Superiorly  it  is 
covered  by  the  fornix. 

The  third  ventricle  has  been  described  above. 

The  optic  thalami  are  two  masses  of  gray  matter  placed 
on  each  side  of  the  third  ventricle. 

The  Midbrain 

The  midbrain  connects  the  pons  Varolii  with  the  inter- 
brain. It  is  composed  of  the  crura  cerebri,  the  corpora 
quadrigemina  and  the  corpora  geniculata. 

The  crura  cerebri  consist  of  fibers  connecting  the 
medulla  with  the  hemispheres.  Each  crus  consists  of  an 
anterior  part,  or  crusta,  and  a  posterior  portion,  or  teg- 
mentum. 

The  corpora  quadrigemina  are  four  eminences  on  the 
dorsal  surface  of  the  midbrain.  Between  the  anterior 
corpora  quadrigemina  is  a  small  conical  body  known  as 
the  pineal  gland. 

The  corpora  geniculata  are  two  small  masses  behind 
the  optic  thalamus  of  either  side. 

The  aqueduct  of  Sylvius  is  a  narrow  canal  in  the  mid- 
brain between  the  corpora  quadrigemina  and  the  teg- 
mentum.   It  connects  the  third  with  the  fourth  ventricle. 


THE  BRAIN 


61 


The  Ceanial  Nerves 

There  are  twelve  pairs  of  cranial  nerves.  The  third 
and  fourth  nerves  arise  from  the  floor  of  the  aqueduct  of 
Sylvius;  the  fifth  to  the  twelfth  nerves,  inclusive,  arise 
from  the  floor  of  the  fourth  ventricle.    These  nerves  leave 


Fig.  23. — Branches  of  the  Facial  Nerve  Spread  Over  the  Face  Like  a 
Fan.    (Campbell.) 

the  skull  through  the  various  foramina  situated  at  the 
base  of  the  skull. 

The  first  nerve,  the  olfactory,  is  the  nerve  of  smell. 
The  fibers  arise  from  the  olfactory  bulb,  pass  through  the 
cribriform  plate,  and  are  distributed  to  the  upper  third 


62   SURGICAL  ANATOMY  OF  THE  MOUTH 


of  the  nasal  septum  and  the  superior  turbinated  bone. 
The  second,  or  optic  nerve,  arises  from  the  optic  com- 
missure, leaves  the  skull  by  the  optic  foramen  and  is  dis- 
tributed  to  the  retina  of  the  eye. 

The  third  nerve,  or  motor  oculi,  leaves  the  skull  by  the 
sphenoidal  fissure,  and  is  distributed  to  all  the  muscles 
of  the  orbit  except  the  superior  oblique  and  the  external 
___ _ rectus.    It  also  sends 

branches  to  the  cili- 
ary muscle  and  the 
sphincter  muscle  of 
the  iris. 

The  fourth  nerve, 
trochlear  or  patheti- 
cus,  leaves  the  skull 
by  the  sphenoidal  fis- 
sure and  supplies  the 
superior-oblique  mus- 
cle of  the  eye. 

The  fifth  nerve,  tri- 
facial, or  trigeminus, 
is  both  a  sensory  and 
motor  nerve.  It  arises 
by  two  roots,  a  motor 
and  a  sensory.  The 
gasserian  ganglion  is  situated  on  its  sensory  root.  A 
short  distance  from  this  ganglion  the  nerve  divides  into 
three  branches :  the  ophthalmic,  the  superior  maxillary 
and  the  inferior  maxillary. 

The  ophthalmic  branch  is  a  sensory  nerve  which  leaves 
the  skull  by  the  sphenoidal  fissure.  It  is  distributed  to 
the  eyeball,  lacrimal  gland,  mucous  membrane  of  the  eye 
and  nose,  and  the  skin  of  the  forehead,  eyebrow  and  nose. 
Its  branches  are  the  lacrimal  frontal  and  nasal. 

The  superior  maxillary  branch  of  the  fifth  is  a  sensory 
nerve,  which  leaves  the  skull  through  the  foramen  rotun- 
dum.    It  is  distributed  to  the  temple,  cheek,  lower  eyelid, 


Fig.  24. — Surface  Markings  of  the  Face 
A,  facial  artery;  B,  facial  vein;  C,  Sten 
son's  duct;  D,  facial  nerve.     (Campbell.) 


THE  BRAIN  63 

nose,  lip,  upper  teeth  and  the  sphenopalatine  ganglion. 
Its  branches  are  the  meningeal,  orbital,  posterior  su- 
perior dental,  middle  superior  dental,  anterior  superior 
dental,  palpebral,  nasal,  labial  and  sphenopalatine. 

The  inferior  maxillary  division  is  both  a  motor  and 
sensory  nerve.  It  leaves  the  skull  by  the  foramen  ovale. 
Its  motor  fibers  supply  the  muscles  of  mastication;  its 
sensory  fibers  supply  the  teeth  and  gums  of  the  lower  jaw 
and  the  mucous  membrane  of  the  anterior  two-thirds  of 
the  tongue.  It  also  supplies  the  skin  of  the  temple,  ex- 
ternal ear,  the  lower  part  of  the  face  and  lower  lip.  Its 
branches  are  recurrent,  internal,  pterygoid,  masseteric, 
deep  temporobuccal  and  external  pterygoid.  It  also  gives 
off  the  auriculotemporal,  lingual  and  inferior  dental.  The 
otic  ganglion  receives  a  branch  of  the  lingual  nerve. 

The  sixth  nerve  leaves  the  skull  through  the  sphenoidal 
fissure  and  supplies  the  external  rectus  muscle  of  the  eye. 

The  seventh  nerve,  or  facial,  leaves  the  skull  by  the 
internal  auditory  meatus,  passes  through  the  aqueductus 
Fallopii  and  appears  on  the  surface  at  the  stylomastoid 
foramen. 

The  nerve  is  divided  into  branches  of  communication 
and  branches  of  distribution. 

The  branches  of  communication  are  the  following:  (a) 
with  the  auditory  nerve,  (b)  with  Meckel's  ganglion  by 
the  large  superficial  petrosal  nerve,  (c)  with  the  optic 
ganglion  by  the  small  superficial  petrosal  nerve,  (d)  with 
the  sympathetic  by  the  external  superficial  petrosal 
nerve,  (e)  with  the  pneumogastric,  (/')  with  the  glosso- 
pharyngeal, {g)  with  the  auriculotemporal  and  finally 
( h)  with  the  auricularis  magnus.  All  the  above  branches 
are  given  off  in  the  aqueductus  Fallopii.  Branches  under 
(b),  (c)  and  (d)  are  given  off  from  the  geniculate  gang- 
lion. After  its  exit  from  the  stylomastoid  foramen,  the 
facial  nerve  communicates  with  the  three  divisions  of  the 
fifth  nerve  and  the  cervical  plexus. 

The  branches  of  distribution  are  as  follows:     Within 


64   SURGICAL  ANATOMY  OF  THE  MOUTH 

the  aqueduct  it  gives  off  the  chorda  tympani  and  the 
branch  to  the  stapedius  muscle.  After  leaving  the  stylo- 
mastoid foramen  it  gives  off  a  posterior  auricular,  the 
stylohyoid  and  the  digastric  branches.  On  the  face  it  is 
divided  into  a  temporofacial  and  a  cervicofacial  branch. 

The  chorda  tympani  enters  the  cavity  of  the  tympanum, 
passes  through  it  and  emerges  from  that  cavity  through 
the  canal  of  Huguier.  It  joins  the  lingual  nerve  and  is 
distributed  to  the  mucous  membrane  of  the  anterior  two- 
thirds  of  the  tongue.  The  digastric  and  stylohyoid 
branches  supply  muscles  of  the  same  name.  The  terminal 
branches  are  distributed  to  the  muscles  of  the  face. 

The  eighth  nerve,  or  auditory,  is  the  nerve  of  hearing. 
It  leaves  the  skull  through  the  internal  auditory  meatus, 
and  is  distributed  to  the  internal  ear. 

The  ninth  nerve,  or  glossopharyngeal,  is  the  nerve  of 
taste.  It  makes  its  exit  from  the  skull  by  the  jugular 
foramen.  It  communicates  with  the  facial,  pneumogas- 
tric  and  sympathetic  nerves.  Its  branches  of  distribution 
are  the  tympanic,  muscular  (to  the  stylopharyngeus  mus- 
cle), pharyngeal,  tonsillar  (to  the  soft  palate  and  fauces) 
and  two  lingual  branches. 

The  lingual  branches  are  the  most  important,  being  dis- 
tributed to  the  base  and  posterior  half  of  the  tongue. 

The  tenth  nerve,  vagus,  or  pneumogastric,  has  a  more 
extensive  distribution  than  any  of  the  other  cranial 
nerves.  It  is  both  motor  and  sensory.  It  is  distributed 
to  the  organs  of  voice  and  respiration,  the.  pharynx, 
stomach,  esophagus  and  heart.  It  leaves  the  skull 
through  the  jugular  foramen,  and  in  this  situation  it 
exhibits  an  enlargement  called  the  superior  ganglion. 
After  its  exit  from  the  foramen,  the  vagus  is  joined  by 
the  accessory  portion  of  the  spinal  accessory  nerve,  and 
at  the  point  of  union  is  a  second  enlargement  called  the 
inferior  ganglion. 

Numerous  branches  are  given  off  from  this  nerve  and 
its  ganglia.     The  most  important  branches  are  the  su- 


THE  BRAIN 


65 


perior  and  recurrent  laryngeal  nerves  and  the  cervical 
and  thoracic  cardiac  branches. 

The  superior  laryngeal  divides  into  the  external  and 
internal  laryngeal.  The  external  laryngeal  supplies  the 
cricothyroid  muscle.  The  internal  laryngeal  is  distrib- 
uted to  the  mucous  membrane  of  the  larynx. 

The  recurrent  laryn- 
geal on  the  right  side 
curves  around  the  sub- 
clavian artery,  and  as- 
cends to  the  larynx.  On 
the  left  side  it  curves 
around  the  arch  of  the 
aorta  and  passes  upward 
in  a  groove  between  the 
trachea  and  the  esopha- 
gus to  the  larynx.  The 
nerves  supply  all  the 
muscles  of  the  larynx  ex- 
c  e  p  t  the  cricothyroid 
muscle. 

The  eleventh  nerve,  or 
spinal  accessory,  consists 
of  two  parts,  the  acces- 
sory portion  and  the 
spinal  portion.  The  ac- 
cessory portion  arises 
from  the  floor  of  the 
fourth  ventricle.  The  spinal  portion  arises  from  the 
spinal  cord  as  low  as  the  sixth  cervical  nerve.  This  nerve 
leaves  the  skull  through  the  jugular  foramen.  The  ac- 
cessory portion  of  the  nerve  is  distributed  to  the  pharyn- 
geal and  superior  laryngeal  branches  of  the  pueumogas- 
tric.  The  spinal  portion  supplies  the  sternomastoid  and 
the  trapezius  muscles. 

The  twelfth,  or  hypoglossal  nerve,  is  the  motor  nerve 
of  the  tongue.    It  leaves  the  skull  by  the  anterior  condy- 


Fig.  25. — The  Laryngeal  Nerves.  A, 
superior  laryngeal  nerve;  B,  recur- 
rent laryngeal  nerve;  C,  superior 
cervical  sympathetic  ganglion. 
(Campbell.) 


66      SURGICAL  ANATOMY  OF  THE  MOUTH 

loid  foramen.  It  communicates  with  the  pneumogastric, 
sympathetic,  the  lingual  and  the  first  and  second  cer- 
vical nerves.  Its  branches  of  distribution  are  the  men- 
ingeal, descendens  hypoglossi,  thyrohyoid  and  muscular 
branches. 

The  descendens  hypoglossi  joins  the  communicating 
branches  from  the  second  and  third  cervical  nerves  to 
form  a  loop  called  the  ansa  hypoglossi.  From  this  loop 
branches  are  given  off  which  supply  the  sternohyoid  and 
the  omohyoid. 

The  thyrohyoid  branch  supplies  the  thyrohyoid  muscle. 

The  muscular  branches  supply  the  styloglossus,  hyo- 
glossus,  geniohyoid,  and  the  geniohyoglossus  muscles. 
The  intrinsic  muscles  of  the  tongue  are  also  supplied  by 
these  branches. 

The  Spinal  Nerves 

The  spinal  nerves  are  arranged  in  pairs,  of  which  there 
are  usually  thirty-two.  Each  nerve  arises  by  roots  from 
the  spinal  cord  and  emerges  from  the  spinal  canal  through 
the  intervertebral  foramen.  Each  nerve  appears  below 
the  corresponding  vertebra,  except  the  first  cervical, 
which  passes  out  of  the  spinal  canal  between  the  skull  and 
atlas.  There  are  eight  cervical  nerves,  twelve  thoracic, 
five  lumbar,  five  sacral  and  one  coccygeal.  The  last  nerve 
is  occasionally  absent. 

After  emerging  from  the  intervertebral  foramen,  each 
nerve  divides  into  an  anterior  and  a  posterior  division 
after  giving  off  a  small  recurrent  branch. 

The  posterior  divisions  are  distributed  to  the  skin  of 
the  back  of  the  trunk,  back  of  the  head,  shoulder,  buttock, 
and  to  the  muscles  of  the  back,  but  not  to  the  muscles  of 
the  limbs. 

The  anterior  divisions,  with  the  exception  of  the  first 
two  cervical  nerves,  are  much  larger  than  the  posterior 
divisions.  They  supply  the  neck,  front  and  sides  of  the 
trunk  and  the  extremities,  uniting  in  various  regions  to 


THE  DIGESTIVE  SYSTEM 


67 


form  plexuses  from  which  important  nerves  originate. 
Each  is  connected  by  a  filament  with  the  sympathetic. 


THE  DIGESTIVE  SYSTEM 

Under  this  head  will  be  described  the  alimentary  canal, 
digestive  glands  and  accessory  parts. 

The  alimentary  canal  consists  of  the  mouth,  pharynx, 
esophagus,  stomach  and 
the  small  and  large  intes- 
tines. 

The  digestive  glands 
include  the  liver,  pan- 
creas and  the  salivary 
glands. 

The  salivary  glands,  of 
which  there  are  three 
pairs, — parotid,  submax- 
illary, and  sublingual, — 
are  placed  about  the  face 
and  secrete  saliva  which 
passes  into  the  mouth 
through  the  ducts  of 
these  glands.  The  liver, 
placed  in  the  abdominal 
cavity,  secretes  the  bile 
which  is  conveyed  into 
the  duodenum  by  the  bile 
duct.  The  pancreas  se- 
cretes the  pancreatic  juice  which  flows  through  the  pan- 
creatic duct  into  the  duodenum. 

The  accessory  parts  include  the  teeth,  tongue,  gums 
and  palate. 

The  Mouth 

The  mouth  is  the  upper  expanded  part  of  the  alimen- 
tary canal.     The  following  parts  of  the  mouth  may  be 


Pig.  mi. — Vertical  Section  of  Mouth 
and  Pharynx.  (After  Deaver.)  A, 
vestibule;  B,  cavity  of  mouth  proper; 
C,  tongue;  B,  hard  palate;  E,  soft  pal- 
ate; F,  uvula;  G,  geniohyoglossus  mus- 
cle; H,  tonsil;  /,  nasopharynx;  J,  ori- 
fice of  Eustachian  tube.     (Campbell.) 


68      SUEGICAL  ANATOMY  OK  TIIU  MOITII 


distinguished:  the  aperture,  placed  between  the  lips;  the 
vestibule,  which  is  the  space  between  the  teeth  internally 
and  the  lips  externally ;  the  cavity  of  the  mouth,  which  is 
bounded  by  the  teeth  externally  and  in  front,  and  which 

opens    behind    into    the 
pharynx. 

The  cavity  of  the 
mouth  is  placed  within 
the  dental  arches.  Its 
roof  is  formed  by  the 
hard  and  soft  palate, 
while  the  floor  is  occu- 
pied by  the  tongue.  By 
raising  the  tongue,  the 
sublingual  region  is  ex- 
posed, and  in  the  middle 
line  under  the  tongue  is 
a  fold  called  the  frenum. 
On  either  side  of  the  fre- 
num may  be  seen  the 
opening  of  Wharton's 
duct  of  the  submaxillary 
gland. 

On  the  other  side  of  the  wall  of  the  vestibule,  opposite 
the  second  upper  molar  tooth,  is  seen  the  opening  of  Sten- 
son's  duct,  which  conveys  the  saliva  from  the  parotid 
gland. 

The  Palate 

The  palate  is  the  arched  structure  which  forms  the 
roof  of  the  mouth.  Its  anterior  portion  is  formed  of 
bone  and  separates  the  nose  from  the  mouth.  The  pos- 
terior part,  the  soft  palate,  is  composed  of  two  layers 
of  mucous  membrane  between  which  are  the  palatine 
muscles,  vessels  and  nerves.  The  soft  palate  separates 
the  nasal  pharynx  above,  from  the  mouth  and  oral 
pharynx  below.    The  posterior  margin  is  free  and  termi- 


Fig.  27. — Palate  and  Alveolar  Arch. 
A,  hard  palate;  B,  soft  palate;  C, 
uvula;  D,  tonsils;  E,  posterior  pala- 
tine artery;  F,  anterior  and  posterior 
pillars  of  fauces.     (Campbell.) 


THE  DIGESTIVE  SYSTEM 


69 


nates  in  a  projection, 
the  uvula.  On  each  side 
of  this  there  extends 
outward  a  pair  of 
ridges,  the  anterior  and 
posterior  pillars  of  the 
fauces.  Between  these 
pillars  is  placed  the  ton- 
sil. 

The  Tongue 

The  tongne  is  the  or- 
gan of  taste.  It  is  com- 
posed of  muscle,  is  cov- 
ered with  mucous  mem- 
brane  and  is   supplied 


Fig.  29.— The  Tongue.  A,  papillae  (fun- 
giform) ;  B,  papillae  (circumvallate)  ; 
C,  foramen  cecum;  D,  lingua  tonsillar 
tissue.     (Campbell.) 


Fig.  28. — The  Under  Surface  of  the 
Tongue.  A,  frenum;  B,  Wharton's 
duct;  C,  sublingual  gland;  D,  ra- 
nine  vein;  E,  lingual  nerve.  (Camp- 
bell.) 

with  blood  vessels,  lym- 
phatics and  nerves.  Its 
base  is  attached  to  the 
hyoid  bone  and  to  the 
epiglottis  by  the  three 
glosso-epiglottic  folds 
o  f  mucous  membrane. 
Its  tip  is  free  and  rests 
against  the  lower  inci- 
sor teeth.  Its  under  sur- 
face is  connected  with 
the  lower  jaw  by  the 
geniohyoglossal  m  u  s  - 
cles. 

The  tongue  is  di- 
vided into  t  w  o  halves 
by  a  median  septum 
which  terminates  pos- 
teriorly in  a  depres- 
sion,   the   foramen 


70   SURGICAL  ANATOMY  OF  THE  MOUTH 


tongue 


cecum,  a  short  distance  from  the  base  of  the  tongue. 
The  mucous  membrane  on  the  dorsum  of  the  tongue  is 
covered  with  elevations  called  papillae.  They  are  of 
three  varieties:  (a)  filiform  papillae  are  the  smallest  and 
are  distributed  over  the  anterior  two-thirds  of  the 
(b)  fungiform  papillae  are  larger  and  less  nu- 
merous than  the  fili- 
form and  are  found 
near  the  tip  and  mar- 
gins of  the  tongue;  (c) 
the  circumvallate  are 
the  largest  of  all  the  pa- 
pillae and  are  arranged 
in  the  form  of  a  "V 
on  the  posterior  part  of 
the  d  o  r  s  u  m  of  the 
tongue. 

The  chief  artery  of 
the  tongue  is  the  ling- 
ual. The  dorsalis  ling- 
uae is  distributed  to  the 
pharyngeal  surface  of 
the  tongue  together 
with  the  tonsillar 
branch  of  the  facial. 

The  nerves  of  the 
tongue  are:  (a)  the  hy- 
poglossal, which  is  the  motor  nerve  of  the  tongue;  (b) 
the  lingual  nerve,  which,  with  the  chorda  tympani  branch 
of  the  facial,  supplies  common  sensation  to  the  anterior 
two-thirds  of  the  tongue ;  (c)  the  glossopharyngeal  nerve, 
which  sends  its  branches  to  the  circumvallate  papillae 
and  the  mucous  membrane  behind  these  papillae.  This 
is  the  nerve  of  taste;  (d)  the  internal  laryngeal  nerve, 
which  also  sends  a  few  fibers  to  the  posterior  part  of  the 
base  of  the  tongue. 


Fig.  30. — Areas  of  Nerve  Distribution 
on  the  Surface  of  the  Tongue.  A, 
areas  supplied  by  the  internal  laryn- 
geal nerve;  B.  area  supplied  by  the 
glossopharyngeal  nerve;  C,  area  sup- 
plied by  the  lingual  nerve.    (Campbell.) 


THE  DIGESTIVE  SYSTEM  71 

The  Salivary  Glands 

The  salivary  glands  include  the  parotid,  submaxillary 
and  sublingual  glands. 

The  parotid  gland  extends  from  the  zygoma  to  the 
angle  of  the  jaw  and  backward  to  the  sternomastoid 
muscle.  Internally  it  lies  on  the  styloid  process  and  an- 
teriorly it  is  continued  over  the  surface  of  the  masseter 
muscle.  The  parotid,  or  Stenson's  duct,  leaves  the  facial 
process  of  the  gland,  crosses  the  masseter  muscle  and 
pierces  the  buccinator  muscle.  It  opens  into  the  mouth 
by  a  small  orifice  opposite  the  second  molar  tooth. 

The  arteries  which  supply  the  glands  are  branches 
from  the  external  carotid.  Traversing  the  substance  of 
the  gland  are  found:  (a)  temporomaxillary  vein;  (b) 
the  branches  of  the  facial  nerve;  (c)  the  external  carotid 
artery  which  divides  into  its  two  terminal  branches  in  the 
gland  substance. 

The  submaxillary  gland  is  placed  in  the  submaxillary 
triangle  partly  under  cover  of  the  lower  jaw.  The  deep 
surface  lies  on  the  myohyoid  muscle,  and  behind  this  on 
the  hyoglossus  muscle.  From  the  deep  surface  of  the 
gland,  a  deep  process  passes  forward  beneath  the  myo- 
hyoid muscle  with  the  duct.  The  submaxillary,  or  Whar- 
ton's duct,  runs  forward  beneath  the  floor  of  the  mouth. 
It  opens  on  the  floor  of  the  mouth  at  the  side  of  the 
frenum  of  the  tongue. 

The  sublingual  gland  is  placed  in  the  floor  of  the  mouth 
between  the  lower  jaw  externally  and  the  geniohyoglos- 
sus  muscle  internally,  and  the  myohyoid  muscle  below. 
Its  ducts  are  called  the  ducts  of  Rivinius.  They  leave  the 
upper  part  of  the  gland  and  open  on  a  series  of  papillae 
which  are  placed  along  the  summit  of  the  plica  sublin- 
gualis. This  gland  is  supplied  by  branches  of  the  lingual 
and  facial  arteries. 


72      SURGICAL  ANATOMY  OF  THE  MOUTH 

The  Teeth 

The  teeth  which  begin  to  appear  in  the  infant  at  about 
the  sixth  month,  are  called  the  temporary  teeth,  while 
those  which  succeed  them  in  the  adult  are  the  permanent 
teeth. 

The  temporary  teeth  are  twenty  in  number.  In  each 
jaw,  beginning  at  the  median  line,  there  are  two  incisors, 
one  canine  and  two  molars. 

The  permanent  teeth  are  thirty-two  in  number.  In 
each  jaw,  beginning  at  the  median  line,  there  are  two 
incisors,  one  canine,  two  bicuspids  and  three  mo- 
lars. 

The  Pharynx 

The  pharynx  is  placed  behind  the  mouth,  larynx  and 
the  nasal  cavities.  It  extends  from,  the  base  of  the  skull 
to  the  sixth  cervical  vertebra,  where  it  passes  into 
the  esophagus.  It  is  about  five  and  a  half  inches  in 
length. 

In  front  of  the  pharynx  are  the  nasal  cavities,  the 
mouth,  the  base  of  the  tongue  and  the  larynx.  Behind 
the  pharynx  are  the  six  upper  cervical  vertebrae  cov- 
ered by  the  vertebral  muscles  and  fascia.  Laterally  are 
placed  the  carotid  sheaths.  Superiorly  the  pharynx  is 
attached  to  the  basilar  process  and  below  it  joins  the 
esophagus. 

The  pharynx  presents  seven  openings  through  which 
it  communicates  with  the  neighboring  cavities.  On  the 
anterior  wall  are  the  two  posterior  nares,  the  opening 
into  the  mouth,  and  the  orifice  of  the  larynx.  On  the 
sides  of  the  nasopharynx  are  the  pharyngeal  orifices  of 
the  eustachian  tubes.  Behind  each  eustachian  tube  is  a 
recess,  the  fossa  of  Rosenmuller.  Below,  the  pharynx 
opens  into  the  esophagus. 


HISTOLOGY  73 

The  Esophagus 

The  esophagus  intervenes  between  tne  pharynx  and  the 
stomach.  It  extends  from  the  lower  border  of  the  cricoid 
cartilage  opposite  the  sixth  cervical  vertebra,  to  the  car- 
diac opening  of  the  stomach  opposite  the  eleventh  dorsal 
vertebra.  It  first  lies  in  the  neck,  traverses  the  thorax, 
and,  piercing  the  diaphragm,  joins  the  stomach.  It  is 
about  ten  inches  in  length  and  about  three-quarters  of 
an  inch  in  diameter.  It  presents  two  constrictions,  one 
at  the  beginning,  the  other  where  it  is  crossed  by  the  left 
bronchus. 

In  the  neck  it  lies  behind  the  trachea  and  in  front  of 
the  vertebrae.  Laterally  are  placed  the  carotid  sheaths 
and  the  lateral  lobes  of  the  thyroid  gland.  In  the  thorax 
the  esophagus  passes  through  the  superior  and  posterior 
mediastinal  spaces. 

HISTOLOGY 

The  digestive  apparatus  consists  of  a  muscular  tube 
that  passes  through  the  body,  the  function  of  which  is 
to  receive  food  materials  and  fit  them  for  use  in  the 
body  economy.  In  this  process  it  is  aided  by  certain 
glandular  elements,  which  secrete  the  fluid  solvents  by 
which  the  disintegration  of  the  food  is  accomplished, 
and  certain  absorbent  elements  by  which  the  nutrient 
materials,  products  of  the  transformed  food,  are  taken 
up  by  the  circulation  and  appropriated  by  various  parts 
of  the  body. 

This  tube  opens  at  each  end  of  the  body :  at  the  upper 
part  on  the  oral  cavity,  and  at  the  lower  extremity  in  the 
anus.  At  certain  points  in  its  course  it  is  in  communica- 
tion with  special  accessory  glands,  which  act  by  pouring 
into  the  tube  some  element  to  aid  in  the  digestive  process, 
or  by  receiving  or  further  elaborating  the  products  of 


74   SURGICAL  ANATOMY  OF  THE  MOUTH 

digestion,  as  for  example,  the  liver,  pancreas,  and  lym- 
phatic system. 

Oral  Cavity 

The  digestive  tract  begins  with  the  oral  cavity.  This 
cavity  contains  the  teeth  and  tongue.  The  teeth  are  for 
the  purpose  of  dividing  the  food  into  smaller  fragments, 
while  the  tongue  serves  as  a  mixer  of  food  and  an  organ 
of  taste  and  tactile  sensation. 

Besides  these,  the  submucous  tissue  of  the  mouth  con- 
tains glands  that  supply  the  fluid  which,  mixed  with  the 
food,  softens  it  and  renders  it  susceptible  to  the  action 
of  the  digestive  fluids.  These  glands  are  known  as  sali- 
vary glands.  There  are  three  pairs, — the  parotid,  sub- 
maxillary, and  sublingual.  In  addition  there  are  numer- 
ous minute  glands  in  the  tissue  of  the  tongue  and  mucous 
surface  of  the  cheeks  and  lips,  which  also  contribute 
their  products  to  the  salivary  fluid  of  the  mouth. 

Mucous  Membrane  of  the  Oral  Cavity.— The  mouth  is 
lined  by  a  mucous  membrane  consisting  of  two  layers. 
The  surface  layer  consists  of  stratified  pavement  epi- 
thelium, already  described,  and  beneath  the  epithelial 
surface  lies  the  stratum  proprium,  or  tunica  propriae, 
which  is  composed  of  fibrous  connective  tissue  in  which 
the  various  glands  are  situated.  This  structure  is  the 
submucous  connective  tissue.  This  whole  structure  very 
closely  resembles  the  skin.  The  pavement  epithelium  is 
stratified  in  the  same  way,  the  difference  being  in  the 
absence  of  the  stratum  granulosum  and  lucidum,  and  the 
fact  that  the  upper  layers  are  not  hornified  and  have  not 
lost  their  nuclei.  The  similarity  is  still  further  observed 
in  the  formation  into  papillae  of  the  stratum  proprium, 
which  represents  the  dermis  of  the  skin.  These  papillae 
project  into  the  epithelial  surface  and  are  larger  or 
smaller  according  to  situation.  On  the  red  margin  of 
the  lips  the  papillae  are  very  high,  while  on  the  rest  of 


HISTOLOGY  75 

the  mucous  membrane  of  the  lips  and  cheeks  they  are  low 
and  broad. 

The  Salivary  Glands 

These  glands  of  the  mouth  belong  to  the  saccular,  or 
racemose  variety  of  glands,  and  furnish  two  kinds  of 
secretion  to  the  saliva :  a  serous,  or  albuminoid,  and  a 
mucous  secretion.  The  serous  secretion  is  a  thin  fluid 
having  in  its  composition  certain  ferments  which  are 
specific  products  of  the  gland  cells.  The  parotid  glands 
furnish  only  a  serous  secretion;  the  sublingual  and  sub- 
maxillary are  mixed  glands  and  furnish  both  serous  and 
mucous  fluids  to  the  saliva. 

Salivary  Cells.— The  cells  of  the  two  kinds  of  glands 
differ  in  structure  and  appearance.  The  mucous  cells 
when  filled  with  secretion  are  clear  and  relatively  larger. 
Their  clearness  is  due  to  large  quantities  of  clear  glob- 
ules of  mucin  contained  in  their  substance.  When  the 
cells  are  full  of  secretion  the  nuclei  are  crowded  back  to 
the  base  of  the  cell.  In  the  submaxillary  and  sublingual 
glands  are  found  two  kinds  of  cells :  the  clear  cell,  and  a 
smaller,  granular  cell.  The  clear  cell  is  the  mucous,  and 
the  granular  one  is  the  serous  cell.  There  are  also  at 
the  outside  of  the  alveoli  numerous  crescent-shaped  cells 
known  as  the  semilunes  or  crescents  of  Oianuzzi. 

Secretion.— When  the  mucous  cell  has  discharged  its 
load  of  mucus,  it  becomes  smaller  and  very  much  more 
granular.  In  the  serous  cells  the  protoplasm  is,  at  one 
state  of  its  activity,  so  crowded  with  granules  that  the 
nucleus  is  obscured,  but  after  the  discharge  of  the  secre- 
tion, the  cytoplasm  is  comparatively  clear.  The  granules 
represent  the  material  in  the  protoplasm  which  becomes 
the  specific  product  of  the  gland  cell.  The  ducts  of  the 
glands  are  lined  by  columnar  epithelium  and  these  cells 
have  at  their  bases  stripes,  which  pass  from  the  base  of 
the  cell  to  its  center,  while  the  balance  of  the  cytoplasm 
toward  the  lumen  is  granular.     These  ducts  furnish  a 


76   SURGICAL  ANATOMY  OF  THE  MOUTH 

secretion  to  the  product  of  the  gland,  and  it  may  be  that 
the  stripes  are  broken  into  granules,  and  these,  in  turn, 
discharged  from  the  cell  to  form  a  part,  at  least,  of  the 
secretory  product. 

It  will  be  remembered  that  the  pancreatic  cell  has 
somewhat  the  same  structure,  and  the  suggestion  was 
made  that  these  structural  elements  contribute  in  this 
way  to  the  formation  of  the  gland  secretion. 

The  duct  of  the  parotid  gland  is  known  as  Stenson's 
duct ;  that  of  the  submaxillary  is  called  the  duct  of  Whar- 
ton; while  that  of  the  sublingual  is  called  the  duct  of 
Bartholin.  The  parotid  opens  into  the  oral  cavity,  op- 
posite the  superior  molar  tooth;  while  the  ducts  of  the 
two  latter  glands,  the  submaxillary  and  sublingual,  unite 
in  a  single  opening  under  the  tongue,  directly  posterior 
to  the  lower  incisors. 

The  Tongue 

This  organ  is  composed  of  voluntary  muscle,  the  fibers 
of  which  pass  in  various  directions  through  its  sub- 
stance. Between  the  bundles  of  muscular  fibers  is  found 
a  greater  or  less  quantity  of  areolar  connective  tissue, 
which  serves  as  a  supporting  medium  for  numerous  race- 
mose glands,  blood  vessels  and  nerves.  The  surface  of 
the  organ  is  covered  by  stratified  pavement  epithelium 
which  rests  upon  a  layer  of  areolar  connective  tissue, 
forming  the  submucous  areolar  tissue  corresponding  to 
the  dermis  of  the  skin.  In  this  submucous  layer  are 
found  most  of  the  blood  vessels,  lymphatics,  and  many 
of  the  nerve  trunks,  together  with  some  lymphoid  tissue. 

Papillae.— The  surface  of  the  tongue  is  elevated  into  a 
series  of  papillae.  The  projections  are  sharp  and 
pointed,  or  low  and  broad,  according  to  situation.  Some, 
attached  at  the  base  of  the  tongue,  are  surrounded  by  a 
deep  depression  and  are  called  circumvallate  x)apillae. 
On  the  sides  of  these  latter  structures  are  certain  groups 
of  specialized  epithelial  cells  known  as  taste-buds.    They 


HISTOLOGY 


t  ( 


belong  to  the  so-called  neuro-epithelium.  Collections  of 
lymph  cells,  resembling  the  solitary  follicles,  are  found  in 
the  submucous  connective  tissue  of  the  tongue  papillae. 

The  Teeth 

These  organs  of  mastication  are  situated  on  the  ridges 
of  the  superior  and  inferior  maxillae.  The  larger  por- 
tion of  these  organs,  the  root,  is  embedded  in  the  alveolus 
of  the  jaw,  while  the  upper  third  stands  above  the  mucous 
tissue,  known  as  the  gum,  and  is  called  the  crown. 

Structurally  the  tooth  consists  of  four  parts,  three  of 
which  are  hard,  bone-like  materials,  while  the  fourth  is 
composed  mostly  of  connective  tissue.  The  hard  parts  of 
the  tooth  are  the  enamel,  which  covers  the  crown,  the 
dentin,  which  makes  up  the  bulk  of  the  root,  and  the 
cementum,  which  covers  the  external  surface  of  the  root 
and  comes  in  contact  with  the  tissues  of  the  jaw  in  which 
the  tooth  is  embedded.  The  center  of  the  tooth  is  occu- 
pied by  the  pulp,  which  is  contained  within  the  central 
cavity,  known  as  the  pulp-chamber. 

The  Enamel. — It  consists  of  a  series  of  rods  or  prisms, 
pointed  at  both  ends  and  thickened  in  the  center,  which 
are  laid  together,  their  tapering  ends  overlapping. 
These  prisms  are  put  together  in  such  a  way  'that  their 
long  diameter  is  directed  toward  the  surface,  and  are 
marked  by  a  series  of  transverse  striations.  The  enamel 
is  the  hardest  substance  in  the  body,  and  consists  of  in- 
organic or  mineral  substances,  mostly  phosphate,  the 
prism  being  held  together  by  a  very  small  amount  of 
organic  substance  called  cement,  so  small  indeed  that  it 
can  hardly  be  demonstrated. 

The  Dentin.— This  constituent  of  the  tooth,  which  is 
known  as  ivory,  is  made  up  of  a  series  of  minute  tubes 
embedded  in  a  matrix  of  bone-like  material.  These  tubes, 
known  as  the  dentinal  tubuli,  pass  through  the  substance 


78   SUBGICAL  ANATOMY  OF  THE  MOUTH 

of  the  dentin  to  the  enamel  of  the  crown,  and  to  the 
cementum  on  the  root.  They  are  larger  and  farther 
apart  at  the  pulp-chamber  and  very  much  branched  as 
they  pass  toward  the  periphery.  At  the  outer  surface, 
or  periphery  of  the  dentin,  they  open  into  a  series  of 
irregular  spaces  known  as  the  interglobular  spaces. 

The  Cementum.  — This  substance,  which  is  a  true  bone, 
forms  a  thin  layer  which  covers  the  root  of  the  tooth  from 
the  point  where  the  enamel  joins  the  dentin.  It  has 
lacunae  and  canaliculi  as  true  bone,  and  like  it  is  covered 
by  a  membrane  which  serves  in  the  double  capacity  of  a 
lining  to  the  process  in  the  jaw  in  which  the  tooth  stands, 
the  alveolar  process,  and  a  periosteal  covering  to  the 
cementum.  This  membrane,  the  peridental  membrane  of 
the  old  histologists,  is  known  as  the  alveolodental  peri- 
osteum. 

The  Pulp.— The  dental  pulp  occupies  the  pulp-chamber 
and  sends  an  extension  through  a  canal,  which  extends 
throughout  the  length  of  the  root  of  the  tooth  and  is 
known  as  the  root  canal.  It  is  composed  of  a  matrix  of 
connective  tissue  in  which  are  embedded  an  artery,  vein 
and  nerve.  At  the  periphery  is  situated  a  membrane 
composed  of  large,  oval  cells  with  conspicuous  nuclei. 
These  cells  are  known  as  odontoplastic  cells.  They  send 
processes  through  the  dentinal  tubuli,  known  as  the  den- 
tinal fibrils,  which  pass  through  the  tubuli  and  fill  the 
interglobular  spaces  with  their  protoplasm.  It  is  said 
by  some  authorities  that  there  are  no  lymphatic  vessels 
in  the  tooth-pulp.  It  seems  to  the  writer  that  this  state- 
ment grows  out  of  an  inadequate  knowledge  of  the  struc- 
ture and  function  of  connective  tissue. 

The  lymphatic  system,  as  stated  elsewhere,  has  its 
origin  in  the  connective  tissue,  or  lymph  spaces.  These 
spaces  are  filled  with  lymph  from  the  blood  which  must 
be  disposed  of  somewhere.  The  question  of  lymphatics 
in  the  connective  tissue  of  the  pulp  has  not  been  invests 


THE  REGION  OF  THE  NECK 


79 


gated  by  anyone  whose  authority  is   of  such  standing 
that  it  can  be  accepted  without  question,  and  we  must 
wait  for  further  knowledge  before  deciding  the  ques- 
tion. Meanwhile  we  shall 
speak   of   lymphatics   in 
the  pulp  as  we  do  of  like 
tissue    elsewhere.   Al- 
though there  may  be  no 
true  lymphatic  vessels 
demonstrable  in  the  pulp, 
it  is  conceivable  that  the 
lymph  spaces  in  the  con- 
nective tissue  may  func- 
tion as  such,  just  as  they 
do  in  the  voluntary  mus- 
cle where  a  like  condition      Fig.  31— The  Primary  Cervical  Tri- 
■    .  angles  Formed  by  the  Sternomas- 

exiStS.  T0ID  Muscle.     (Campbell.) 


THE  REGION  OF  THE  NECK 


^ 


Fio.  32. — Triangles  of  the  Neck. 
A,  submaxillary  triangle;  B,  supe- 
rior carotid  triangle;  C,  inferior 
carotid  triangle;  D,  occipital  trian- 
gle; K.  supraclavicular  triangle. 
(Campbell.) 


The  arrangement  of  the 
muscles  on  the  side  of  the 
neck  is  such  that  they  are 
divided  into  a  series  of 
triangles.  For  descriptive 
purposes  the  lateral  as- 
pect of  the  neck  may  be 
regarded  as  a  quadrilat- 
eral space,  the  upper 
boundary  being  the  lower 
border  of  the  jaw  and  a 
line  extending  from  the 
angle  of  the  jaw  to  the 
tip  of  the  mastoid.  The 
lower  boundary  is  formed 
by  the  clavicle,  the  sides 
of  the  median  line  of  the 


80   SURGICAL  ANATOMY  OF  THE  MOUTH 

neck  in  front,  and  the  trapezius  muscle  behind.  This 
space  is  divided  into  two  by  the  sternomastoid  muscle, 
which  runs  diagonally  from  the  mastoid  to  the  sterno- 
clavicular joint.  In  this  way  the  two  primary  triangles 
are  formed.     The  anterior  triangle  is  crossed  obliquely 


Fig.  33. — The  Outer  Kegion  of  the  Neck,  Showing  the  Occipital  and 
Supraclavicular  Triangle.  The  omohyoid  is  indicated  semitranspar- 
ently.     (Campbell.) 


by  the  digastric  muscle  above,  and  by  the  anterior  belly 
of  the  omohyoid  below,  and  is  thus  divided  into  three 
triangles;  the  submaxillary,  and  the  superior  and  inferior 
carotid  triangles.  The  posterior  triangle  is  divided  by 
the  posterior  belly  of  the  omohyoid  into  an  occipital  and 
subclavian  triangle.  In  addition  to  the  regions  covered  by 
these  triangles  there  is  the  median  visceral  region  ex- 
tending from  the  hyoid  bone  to  the  sternal  notch. 


THE  EEGION  OF  THE  NECK 

: , 


81 


Fig.  34.— Surface  Markings  of  the  Anterior  Part  of  the  Neck.  A,  hyoid 
bone;  B,  thyrohyoid  membrane;  C,  thyroid  cartilage;  D,  cricothyroid 
membrane;  E,  cricoid  cartilage;  F,  thyroid  isthmus;  G,  trachea.  (Camp- 
bell.) 


The  Vessels  of  the  Neck 

The  common  carotid  artery  takes  its  origin  from  the 
innominate  artery  on  the  right  and  from  the  arch  of  the 
aorta  on  the  left.  In  the  neck  the  course  -of  the  artery 
is  indicated  by  a  line  drawn  from  the  sternoclavicular 
joint  to  a  point  just  in  front  of  the  mastoid  process.  It 
extends  from  the  sternoclavicular  articulation  to  the 
upper  border  of  the  thyroid  cartilage,  where  it  divides 
into  the  external  and  internal  carotid.  The  common 
carotid  gives  off  no  branches  in  the  neck  and  is  always 
in  an  intimate  relation  with  the  sternomastoid  muscle. 
It  is  contained  in  a  sheath  together  with  the  internal 
jugular  vein  and  pneumogastric  nerve. 

The  internal  and  external  carotid  arteries  are  the 
terminal  branches  of  the  common  carotid  which  divides 
opposite  the  upper  border  of  the  thyroid  cartilage.    At 


82   SURGICAL  ANATOMY  OF  THE  MOUTH 

their  origin  they  lie  side  by  side  in  close  relation  to  the 
jugular  vein.  The  internal  carotid  gives  off  no  branches 
in  the  neck  but  is  distributed  to  the  brain  and  the  eye. 
The  external  carotid  is  the  smaller  of  the  two  terminal 
branches  supplying  the  face  and  the  soft  parts  covering 


Fig.  35. — The  Carotid  Region  and  the  Chief  Structures.  Note  the  re- 
lation of  the  internal  jugular  vein,  the  common  carotid  artery  and  the 
pneumogastric  nerve.     (Campbell.) 


the  vault  of  the  cranium.  Its  branches  are  the  superior 
thyroid,  lingual  and  facial  arteries  which  supply  the  thy- 
roid gland,  tongue  and  face  respectively.  Posteriorly 
it  gives  off  the  occipital  and  posterior  auricular  arteries. 
Superiorly  it  gives  off  the  internal  maxillary  and  super- 


Fig.  36. — The  Chief  Arteries  op  the  Neck.  (Dcaver,  modified.)  A,  com- 
mon carotid;  B,  external  carotid;  C,  internal  carotid;  D,  vertebral. 
(Campbell.) 


83 


84   SURGICAL  ANATOMY  OF  THE  MOUTH 

ficial  temporal  arteries.     There  is  also   a   small   trunk 
known  as  the  ascending  pharyngeal  artery. 

The  internal  jugular  vein  takes  its  origin  at  the  base 
of  the  cranium,  where  it  receives  practically  all  the  blood 
from  the  cranial  cavity.  It  is  always  in  close  relation 
with  the  carotid  arteries  and  pneumogastric  nerve.  Sur- 
gically it  is  of  very  great  importance,  as  its  large  size 
and  thin  walls  render  it  especially  liable  to  injury. 


CHAPTER   II 

RECENT   ADVANCES    IN    PHYSIOLOGY 
George  Van  Ness  Dearborn,  A.  B.,  M.  D.,  Ph.  D. 

INTERNAL    SECRETION 

Scope  of  Chapter.— The  object  of  this  chapter  is  to 
set  forth  the  recent  physiological  advances  that  have  been 
made.  Their  order  has  no  significance.  Of  course  every 
one  knows  that  general  physiology  includes  everything 
from  the  soles  of  the  feet  to  the  top  of  the  head,  but  by 
far  the  most  important  studies  made  in  physiology  in  the 
past  ten  years  have  related  to  the  internal  secretions. 
There  has  perhaps  been  more  research  of  importance 
along  this  line  of  the  internal  secretions  than  in  any  other 
one.  The  term  ductless  gland  might  perhaps  better  be 
used. 

Ductless  Glands.— The  very  fact  that  these  glands  are 
ductless  implies  that  their  products  are  absorbed  into 
the  circulation  instead  of  passing  out  into  some  body 
cavity.  More  physiological  researches  have  been  con- 
ducted upon  these  glands  than  with  regard  to  any  other 
organ,  because  they  have  been  found  to  have  far  more 
to  do  with  the  conduct  of  the  body  than  was  formerly 
supposed.  To  have  to  treat  of  the  subject  of  the  ductless 
glands  in  a  superficial  way  is  very  unsatisfactory  because 
so  many  researches  have  been  made,  under  the  most  com- 
plex conditions,  that  oftentimes  the  present  apparent  re- 
sults are  highly  contradictory.  It  is  perfectly  possible 
to  encounter  ten  or  fifteen  didactic  statements,  of  great 
interest,  made  by  reliable  workers  about  the  functions 

85 


86       RECENT  ADVANCES  IN  PHYSIOLOGY 

of  the  ductless  glands,  only  to  find  these  statements  con- 
tradicted by  equally  eminent  authority.  That  is  hap- 
pening all  the  time,  and  there  is  scarcely  anything  in  re- 
gard to  the  physiology  of  the  ductless  glands  that  could 
be  said  didactically  of  which  the  reader  cannot  find  a 
contradiction  made  by  some  good  research  authority. 
Consequently,  although  of  immense  interest  in  some  ways 
to  military  dentists,  it  is  difficult  to  make  definite  state- 
ments regarding  the  hormones,  save  in  a  few  minor  par- 
ticulars, with  which  the  reader  is  already  more  or  less 
familiar. 

Hormones  and  Koliones 

Some  of  these  internal  secretions,  or  hormones  and 
koliones,  will  now  be  briefly  considered,  the  hormones 
being  actuating  products  and  the  koliones  (or  "cha- 
lones")  inhibitory  in  their  effects. 

Adrenalin. — In  the  first  place  adrenalin  will  be  men- 
tioned. There  are  four  or  five  substitutes  or  synonyms 
for  that  word.  It  is  the  product  of  the  cortex  of  the 
adrenal  gland,  which  most  physiologists  used  to  call  the 
suprarenal  capsule.  There  is  here  the  same  substance 
producing  contradictory  effects, — a  very  small  amount 
producing  contraction  and  a  still  smaller  dose  relaxa- 
tion of  the  smooth  or  vegetative  muscle.  This  is  a  good 
example  illustrative  of  the  difficulty  of  dealing  even  with 
the  most  certain  and  longest  known  of  the  internal  secre- 
tions. A  certain  amount  of  adrenalin  constricts,  and  a 
smaller  amount  relaxes,  the  smaller  arteries. 

Adrenalin  in  Fatigue. — Professor  Cannon,  who  is 
at  present  engaged  in  research  work  in  France  on  an 
internal  secretion  in  relation  to  shock,  pointed  out 
that  this  substance  does  away  very  largely  with  signs  of 
fatigue. 

He  showed  by  actual  experiment  that  adrenalin  injected 
into  the  veins  of  a  fatigued  animal  would  rest  that  ani- 
mal in  five  minutes  as  much  as  two  hours  of  natural  rest. 


INTERNAL  SECRETION  87 

Just  how  this  resting  effect  is  brought  about  remains  to 
be  shown.  Very  likely  it  has  something  to  do  with  the 
nutrition  of  the  nerve  cells.  That  is  very  important,  but 
still  vague. 

Effect  on  Blood  Composition. — Another  thing  with 
which  adrenalin  has  to  do  is  the  coagulation  of  the  blood. 
Moreover,  it  brings  about  in  some  way  an  increase  of 
dextrose  in  the  blood.  In  general,  these  various  func- 
tions of  the  adrenal  glands  are  all  related  to  the  dynamic 
aspects  of  the  animal  and  to  the  amount  of  energy  which 
it  can  expend.  Adrenalin,  then,  is  the  index  of  emotional 
bodily  power.  The  coagulation  of  the  blood  is  a  neces- 
sary thing  for  an  animal  about  to  go  into  combat,  for  in 
a  good  old-fashioned  cat-fight  blood  flows  freely.  Under 
these  clamorous  conditions  it  is  necessary  for  the  blood 
to  coagulate  promptly,  the  more  surely  to  save  the  animal 
from  bleeding  to  death.  All  these  results  mentioned  are 
means  of  increasing  the  possible  energy-expenditure  on 
the  part  of  the  animal.  That  on  the  whole  is  one  of  the 
most  important  contributions  to  physiology  in  the  last 
few  years.  The  cortex  of  the  suprarenal  capsules  has 
much  to  do  with  the  fitting  of  the  blood  for  unusual  mus- 
cular exertion. 

Thyroid.— The  secretion  of  the  thyroid  ("colloid") 
is  probably  familiar  to  all.  The  older  work  has  been  cor- 
roborated. There  are  one  or  two  new  things,  one  being 
the  possible  relation  of  colloid  to  tooth-anabolism.  The 
nervous  conditions  known  as  Graves'  disease,  and  myxe- 
dema, are  known  of  old  and  need  merely  to  be  mentioned 
here. 

Parathyroids.— The  parathyroids  have  recently  been 
studied  with  some  effect.  These  are  four  glands  no 
bigger  than  the  end  of  the  thumb,  situated  on  each 
side  of  the  thyroid  in  the  neck,  and  so  closely  adher- 
ent to  the  thyroid  that  it  was  not  realized  at  first  that 
they  were  not  part  of  it.  The  parathyroids  seem  to  be 
concerned  with  the  metabolism  of  the  bone  in  some  way, 


88       RECENT  ADVANCES  IN  PHYSIOLOGY 

but  just  in  detail  what  that  relationship  is  remains  to  be 
seen.  When  the  parathyroids  are  diseased  the  bones 
and  the  teeth  become  soft,  and  thus  lack  the  normal  char- 
acteristics of  ordinary  bone. 

Hypophyseal  or  Pituitary  Body.— The  same  is  true  of 
the  hypophysis  or  pituitary  body.  The  pituitary  is  con- 
cerned in  some  important  way  with  the  metabolism  of 
lime  (calcium),  so  that  the  bone  is  affected  when  the 
pituitary  is  deranged.  Dr.  Harvey  Cushing,  the  director 
of  the  Peter  Bent  Brigham  Hospital  here  in  Boston,  at 
the  present  time  is  a  research  authority  on  the  structure 
and  functions  of  the  pituitary;  but  here  again  there  are 
doubts. 

Epiphyseal  or  Pineal  Body.— The  pineal  gland,  or 
epiphysis,  has  recently  been  studied,  and  is  now  known 
to  be  a  depressor  of  the  blood  pressure,  for  one  thing, 
and  acts  by  lowering  arterial  tension.  The  blood  pres- 
sure and  the  trophic  processes  are  deranged  when  the 
pineal  gland  is  thrown  out  of  working  order.  This  gland 
is  famous  as  the  minute  structure  in  which  the  French 
philosopher  Descartes,  of  the  early  17th  Century,  lo- 
cated the  human  soul ! — an  illustration  of  the  absurdity 
to  which  man  sometimes  will  go  in  the  hope  of  system- 
atizing things  under  the  compulsion  of  "authority." 

Secretions  of  Ovary  and  Testis.— The  ovary  and  the 
testis  have  internal  secretions.  It  is  now  known  that 
these  secretions  have  to  do  with  muscular  vigor,  to  a 
considerable  extent,  both  directly  and  indirectly.  They 
are  concerned  in  muscular  development,  too.  A  boy,  for 
example,  ten  years  of  age  cannot  be  trained  in  a  physical 
sense  at  all.  His  muscles  are  incapable  of  the  growth  and 
hardness  which  are  seen  when  a  man's  muscles  are  prop- 
erly trained.  The  reason  is  that  the  organism  at  that 
early  age  lacks  the  internal  secretions  of  the  testis  which 
they  will  have  later.  The  same  is  true  of  the  ovaries  of 
the  female.  The  corpus  luteum  vera  of  the  ovary  is  now 
to  be  had  in  tablet  form  and  is  of  very  great  importance 


INTERNAL  SECRETION  89 

in  some  nervous  conditions  of  the  menopause,  and  in 
some  other  conditions  of  deranged  reproductive  func- 
tion. 

Secretion  of  Pancreas.— The  pancreas  also  has  an  in- 
ternal secretion.  There  is  no  one  "mix-up"  which  is 
more  complicated  than  the  exact  relations  of  the  pancreas 
to  the  thyroid,  etc.,  in  the  metabolism  of  sugar.  It  is  in 
some  way  related  to  diabetes,  and  to  the  presence  of 
sugar  in  the  urine,  but  just  what  that  relationship  is,  is 
not  accurately  known  as  yet. 

Secretion  of  Thymus.— The  thymus,  which  is  at  its 
height  in  the  child  at  the  age  of  two  years,  has  an  impor- 
tant secretion.  One  of  the  most  suggestive  of  recent  dis- 
coveries is  that  the  thymus  is  an  inhibitor  of  the  develop- 
ment of  the  sexual  apparatus.  Occasionally  one  finds 
one  of  these  extremely  sad  cases  of  a  child  becoming  a 
woman  at  the  age  of  five,  with  perfectly  developed  repro- 
ductive mechanism.  In  these  cases  one  always  finds  that 
the  thymus  gland  is  more  or  less  diseased.  The  thymus 
therefore  seems  to  be  an  inhibitor  of  the  development  of 
the  reproductive  apparatus ;  and  it  also  apparently  has 
to  do  with  adenoid  tissue.  It  is  related  in  its  action 
somehow  especially  to  the  epiphysis. 

Other  Probable  Secretions. — The  carotid  glands,  back 
of  the  carotid  arteries,  have  an  internal  secretion.  The 
spleen  perhaps  has  an  internal  secretion.  The  prostate 
has  an  erotic  internal  secretion.  The  kidney  has  a  vaso- 
motor internal  secretion,  perhaps.  Thus  it  may  be  seen 
what  a  large  number  of  these  internal  secretions  there 
are.  A  number  of  them  are  interrelated,  and  Cannon  and 
his  colleagues  in  the  Harvard  Physiological  Laboratory 
are  engaged  in  working  out  their  relationships. 

Professor  Cannon,  it  is  rumored,  has  made  an  impor- 
tant discovery  in  regard  to  the  abolition  of  shock.  It  is 
said  that  lie  has  discovered  how  an  internal  secretion  may 
abolish  "surgical"  shock,  and  if  it  be  true,  of  course  it  is 
one  of  the  most  important  discoveries  of  recent  decades. 


90       RECENT  ADVANCES  IN  PHYSIOLOGY 

METABOLISM 

Advances  in  Dietetics.— Another  important  advance 
that  has  been  made  in  physiology  relates  we  will  say  to 
dietetics,  although  these  matters  should  not  strictly  be 
spoken  of  as  discoveries  at  all.  But  there  has  been  a 
recent  cohering  and  intercorrelation  of  practical  diet- 
etic facts  and  principles.  The  best  the  writer  can  do 
here  is  to  give  his  opinion  at  random  of  some  of  the  more 
important  conclusions  that  have  come  out  of  recent  re- 
search and  its  application.  There  is  general  feeling,  for 
one  thing,  that  perhaps  the  best  rule  in  regard  to  the  use 
of  protein  is  to  eat  meat  only  once  a  day.  That  is  an 
easy  rule  for  everyone  to  learn,  for  anyone  can  remember 
a  simple  rule  like  "meat  once  a  day."  Under  meat  are 
included  eggs  and  fish,  for,  as  the  reader  knows,  fish-meat 
is  much  like  flesh-meat,  except  that  it  contains  somewhat 
more  water  and  less  fat.  This  is  the  modern  opinion  as 
to  the  use  of  protein  in  the  human  diet. 

Vitamines. — ' '  Vitamines ' '  recently  have  excited  a  good 
deal  of  popular  attention ;  in  fact,  they  have  been  made 
a  fad  of  when,  physiologically  speaking,  there  is  no  rea- 
son for  it.  The  vitamine  "problem"  is  of  no  practical 
importance  to  the  majority  of  ordinary  people,  for  those 
who  have  money  enough  to  buy  even  a  reasonable  all- 
round  diet  have  a  simple  means  of  acquiring  all  the  vita- 
mines they  need,  as  vitamines  are  found  in  all  ordinary 
foods  in  abundance.  This  question,  then,  like  many 
others,  is  a  purely  academic  problem,  except  in  very  ex- 
ceptional cases.  Chinamen  who  are  so  poor,  and  some  of 
the  poorer  "white  trash"  in  the  South  who  are  so  trashy 
that  they  have  not  been  able  to  get  anything  except  rice 
to  eat,  have  sometimes  suffered  from  a  fatal  disease  called 
beriberi;  and  this  has  apparently  been  traced  to  the  ab- 
sence of  certain  substances  found  in  the  coverings  of  the 
grain.    Victims  of  beriberi  lived  on  polished  rice  with  all 


CENTRAL  NERVOUS  SYSTEM      91 

the  coverings  removed,  made  so  "good"  and  so  "pure" 
that  it  was  too  angelic  for  normal  human  use.  The  prob- 
lem, then,  of  vitamines  is  not  one  of  any  practical  account 
for  ordinary  dietetics.  The  vitamines  appear  to  be  com- 
plex lipoidal  substances,  partly  fat  and  partly  protein, 
the  lack  of  even  minute  quantities  of  which  gives  rise  to 
certain  severe  derangements  of  the  nervous  system.  Vita- 
mines are  found  in  all  grains,  in  most  vegetables,  in  all 
kinds  of  meat,  so  that  a  person  living  on  a  mixed  diet, 
however  inexpensive,  is  sure  to  have  an  abundance  of 
vitamines.  The  word  has  become  a  fad.  The  subject  of 
vitamines  has  become  so  familiar  in  the  medical  profes- 
sion that  it  has  long  since  ceased  to  excite  comment. 

Obesity.— Obesity  has  attracted  a  good  deal  of  atten- 
tion recently.  The  importance  of  not  becoming  obese  has 
been  emphasized  in  some  quarters.  It  is  perfectly  ob- 
vious to  physiology  at  the  present  time  that  to  be  obese 
is  to  put  a  mortgage  at  high  interest  both  on  happiness 
and  on  life-expectation ;  and  there  is  no  need  of  it.  Mod- 
ern physiology  knows  how  to  suggest  a  diet  combined 
with  exercise  which  will  keep  anyone  from  becoming  over- 
weight as  long  as  his  internal  arrangements,  hormones 
and  koliones  especially,  are  in  good  working  order. 

Villi  of  Small  Intestine.— In  relation  to  the  diet, 
a  word  would  not  be  amiss  here  in  regard  to  the  move- 
ments of  the  villi  of  the  small  intestine.  In  the  small  in- 
testine of  the  human  animal  there  are  about  4,000,000  villi 
and  these  are  now  known  to  have  actual  muscular  pump- 
ing movements  of  their  own.  It  has  become  obvious  that 
there  may  well  be  some  sort  of  arrangement  between  this 
action  of  the  villi  and  the  adapted  nutrition  of  the  nerve 
cells. 

CENTRAL  NERVOUS  SYSTEM 

Unmedullated  Nerve  Fibers.— Another  thing  in  re- 
lation to  the  nervous  system,  the  fourth  point  in  this  frag- 


92       RECENT  ADVANCES  IN  PHYSIOLOGY 

mentary  summary,  was  demonstrated  recently  by  Profes- 
sor S.  W.  Ransom  of  the  Northwestern  University  Medi- 
cal School.  He  has  shown  that  for  the  most  part  the  un- 
medullated  fibers  of  the  nervous  system,  part  of  the  sym- 
pathetic nervous  system,  are  undoubtedly  protopathic 
sensory  nerves.  They  represent  the  sensations,  painful 
and  otherwise,  caused  by  the  compression  and  disten- 
tions of  the  viscera.  When  a  person  eats  eight  green 
apples  against  urgent  advice,  in  the  course  of  four  or  five 
hours  he  will  have  a  "pain  in  his  stomach" — where  it 
really  ought  to  be !  That  pain  is  caused  by  the  undue  ir- 
ritation of  these  unmedullated  fibers  of  the  autonomic 
nerves.  The  writer's  chief  interest  in  this  matter  is  psy- 
chological, for  it  is  clear  that  these  fibers  are  in  part  the 
channels  of  supply  of  the  subconscious  aspect  of  the 
mind.  For  some  years  it  has  seemed  that  the  subcon- 
scious mind  is  activated  by  subsensory  impulses,  those 
which  are  not  felt.  This  physiologist  at  the  Northwest- 
ern University,  without  any  probable  interest  in  this 
matter  at  all,  has  proven  that  these  unmedullated  fibers 
are  afferent  or  sensory  nerves. 

Cortex  of  Brain.— The  cortex  of  the  brain  undoubt- 
edly is  a  unit  in  its  action.  It  appears  not  to  be  divided 
into  contiguous  horizontal  areas  as  was  thought,  as  a 
remnant  of  Goll's  phrenology;  on  the  other  hand  the 
cortex  of  the  brain  probably  acts  as  a  unit  in  some  sense. 
At  least  ten  thousand  million  neurons  compose  its  net- 
work of  connecting  pathways,  but  it  appears  more  and 
more  certain  that  they  always  act  more  or  less  in  some 
kind  of  interdependent  unison. 

Brain  Cortex  as  an  Inhibitory  Organ.— The  cortex  of 
the  brain  has  a  chief  function  as  an  inhibitory  organ.  One 
thinks  more  and  more  of  the  human  cortex  as  an  inhibi- 
tory or  restraining  fabric  whose  office  it  is  to  keep  under 
control  and  to  adapt  the  urgent  impulses  of  the  remain- 
der of  the  nervous  system.  The  result  in  actual  social  life 
whenever  the  cortex  is  seriously  injured  so  that  its  in- 


CENTRAL  NERVOUS  SYSTEM      93 

hibitory  control  is  shut  off,  as  in  intoxication,  is  to  make 
an  animal  of  even  a  cultured  human  being.  The  con- 
trolling impulses  come  then  from  the  spinal  cord,  and  the 
human  being  degenerates  for  the  time  into  what  is  prac- 
tically a  brute  animal.  This  line  of  argument  makes  one 
believe  that  the  cortex  of  the  brain  properly  is  an  in- 
hibitory nervous  organ. 

Mechanism  of  Central  Nervous  System  Described  by 
Dercum.— Some  years  ago  Dercum,  the  neurologist,  sug- 
gested a  simile  which  is  of  very  great  interest  and  value 
in  connection  with  the  basal  functions  of  the  nervous 
system. 

He  said  that  one  could  compare  the  action  of  the 
body  and  its  control  by  the  nervous  system  to  the  work- 
ing of  one  of  the  big  modern  steamships.  In  such  a 
great  machine  there  are  two  essential  parts.  There 
is  in  the  first  place  the  engine-hold.  Here  are  the 
fuel  arrangements  and  the  engines,  and  intelligent  men, 
the  stokers  and  engineers,  who  have  charge  of  those 
motor  arrangements.  Now  the  engineers  and  stokers 
down  in  the  hold  of  the  steamship,  whose  business  it  is  to 
understand  the  working  of  the  machinery  which  makes 
the  vessel  go,  have  no  knowledge  necessarily  of  where 
the  vessel  is  going.  It  is  their  sole  business  to  make  the 
vessel  go  precisely  as  directed  from  the  bridge  of  the 
ship;  it  is  their  business  to  keep  it  going  or  at  rest  as 
directed.  If  the  engineer  gets  the  order,  "full  speed 
astern"  or  "ahead,"  it  is  none  of  his  immediate  business 
whether  the  ship  goes  on  the  rocks  or  not.  That  part  of 
the  ship  corresponds  to  the  spinal  cord,  and  to  those 
parts  of  the  nervous  system  that  are  concerned  with  the 
immediate  control  of  the  fabric  of  muscles  and  the  glands. 
It  is  now  pretty  generally  admitted  that  the  brain  knows 
nothing  of  the  precise  work  of  the  actual  muscles.  Now, 
on  the  other  hand,  the  commanding  officers  of  this  ship, 
the  navigators,  may  know  nothing  of  the  engines  at  all. 
The  only  communication  between  the  dominant  bridge  of 


94       RECENT  ADVANCES  IN  PHYSIOLOGY 

the  steamship  and  the  engineers  is  held  by  means  of  sim- 
ple signals  mostly  made  on  bells.  These  signals  back 
and  forth  correspond  to  the  impulses  between  the  cortex 
of  the  brain  and  the  spinal  column.  The  officers  of  the 
ship,  corresponding  to  the  cortex  of  the  brain,  know 
what  they  want  done  but  know  nothing  at  all  about  the 
engines  down  in  the  hold  which  mechanically  do  it.  They 
know  what  they  want  the  boat  to  do,  whether  they  want 
it  to  go  fast  or  slowly,  and  where  they  want  it  to  go. 
The  cortex  of  the  brain  acts  in  much  the  same  way.  In 
other  words,  more  and  more  centers  that  correspond  to 
particular  movements  of  the  body  are  found  in  the  cor- 
tex of  the  brain ;  but  the  cortex,  so  far  as  we  know, 
has  nothing  to  do  with  the  "separate"  muscles.  The 
cortex  controls  the  body  much  as  the  officers  on  the  bridge 
control  the  vessel.  The  cortical  control  of  the  body  is 
by  simple  signals  which  it  sends  down  into  the  spinal 
cord  and  autonomic  system  just  as  the  officer  of  the 
bridge  sends  signals  down  to  the  hold  of  the  ship.  This  is 
a  highly  illuminating  simile,  which  is  capable  of  being 
worked  out  very  far. 


THEORIES  IN  REGARD  TO  VENTILATION 

The  Skin.— Another  direction  in  which  some  progress 
has  been  made  recently  is  in  regard  to  the  skin.  One 
thinks  now  of  the  skin  as  a  very  important  organ.  Just 
because  it  happens  to  be  spread  out  in  a  layer  over  the 
surface  of  the  body  like  the  shell  of  the  tortoise  is  no 
reason  at  all  why  it  should  lack  its  important  functions. 
The  skin  is  now  seen  to  have  much  more  to  do  with 
control  of  the  body  than  was  formerly  supposed. 

Ventilation  of  Lungs  Aided  by  the  Skin.— The  physiol- 
ogist Bohr,  of  Copenhagen,  who  died  too  early,  made  a 
very  good  attempt  to  prove  that  the  skin  was  the  seat  of 
essential    reflex    mechanism    concerned    in    respiration, 


THEORIES  IN  REGARD  TO  VENTILATION      95 

and  that  the  skin  therefore  has  a  good  deal  to  do  with 
the  ventilation  of  the  lungs.  Recently  a  commission  in 
New  York  State  has  been  studying  the  relations  of  men- 
tal efficiency  to  the  ventilation  of  the  schoolroom,  and 
has  again  shown  that  the  amount  of  carbon  dioxid  has 
little  to  do  with  the  mental  efficiency  of  the  pupil.  An- 
derson, of  Yale,  working  in  a  Harvard  laboratory,  stayed 
in  a  room  where  the  atmosphere  contained  8,000  per  cent 
of  carbon  dioxid  with  no  more  inconvenience  than  head- 
ache and  general  malaise.  The  commission  in  New  York 
has  been  working  on  temperature  and  humidity  and  has 
found  no  direct  and  certain  relationship  between  these 
and  mental  efficiency,  though  with  children  under  usual 
conditions  it  may  prove  differently. 

Movement  of  Air  Important.— It  is  the  movement  of 
the  air  that  seems  to  be  the  important  thing,  and  it  is 
the  stagnation  of  the  atmosphere  which  does  the  damage. 
One  might  imagine  that  these  remarks  were  instigated 
by  manufacturers  of  electric  fans  because  electric  fans 
are  so  important  if  these  "current  researches"  are  fully 
corroborated.  The  most  important  feature  of  the  at- 
mosphere, so  far  as  comfort  and  efficiency  are  concerned, 
now  appears  to  be  its  stagnation  or  its  relative  motion. 
As  long  as  the  air  is  in  movement  over  the  skin  the  con- 
ditions pro  tanto  are  ideal.  One  can  have  too  much  of 
many  atmospheric  constituents,  but  the  important  thing, 
so  far  as  hygiene  is  concerned,  seems  to  be  the  movement 
of  the  air  over  the  skin.  According  to  this  discovery  one 
must  work  out  of  doors,  must  have  outdoor  air  indoors, 
or  else  must  use  electric  fans;  one  must  leave  the  win- 
dows far  open  if  one  wishes  to  have  both  comfort  and 
high  mental  efficiency.  Care  must  be  taken  that  living 
rooms  approach  as  nearly  as  possible  out-of-doors  condi- 
tions when  there  is  a  breeze.  Recent  reports  from  many 
Health  Commissions  emphasize  the  fact  that  movement 
of  the  air  is  an  essential  factor  in  maintaining  hygienic 
conditions. 


96       RECENT  ADVANCES  IN  PHYSIOLOGY 

VASOMOTOR  MECHANISM 

Sleep.— Sleep  has  recently  been  studied  by  J.  F.  Shep- 
ard,  a  psychologist  at  the  University  of  Michigan.  He 
has  recently  studied  the  human  brain  in  sleep  through 
large  skull  openings,  one  a  trephine  opening  and  one 
accidental;  and  finds  that  the  blood  in  the  brain  is  in- 
creased during  sleep.  This  is  perhaps  the  best  oppor- 
tunity that  anyone  has  ever  had  to  study  the  volume  of 
blood  in  the  human  brain  during  this  state.  He  had  two 
different  men  to  work  with,  each  with  a  large  opening  in 
the  skull  through  which  the  brain  could  be  studied,  for 
a  year  or  two,  comfortably  and  at  leisure,  and  he  had 
ideal  opportunities  for  good  observation.  Since  Shep- 
ard's  research  it  can  be  said  that  the  blood  is  increased 
in  the  brain  during  sleep,  although  its  pressure  is  re- 
duced. Sleep  used  to  be  considered  a  condition  induced 
by  a  lessening  of  the  blood  supply,  and  that  statement  is 
often  found  in  medical  literature,  but  it  would  now  ap- 
pear to  be  a  condition  in  which  there  is  an  abundance  of 
blood  in  the  brain,  perhaps  for  the  purpose  of  more  rap- 
idly resting  the  neurons,  but  probably  under  very  low 
pressure.  These  two  things  are  very  different.  The 
amount  of  blood  and  pressure  are  sometimes  opposed 
physiological  conditions. 

Vasomotor  Nerves.— Another  point  that  has  been  re- 
cently studied  more  or  less  is  in  connection  with  the 
vasomotor  mechanism..  We  now  have  a  fairly  good  idea 
of  what  its  functions  are.  The  nerves  have  been  dis- 
covered throughout  the  brain  and  in  every  part  of  the 
body.  The  increases  and  decreases  in  caliber  of  the 
smaller  arteries  constitute  one  of  the  most  important  of 
physiological  processes.  Everyone  knows  that  there  are 
two  sets  of  vasomotor  nerves — the  dilator  and  the  con- 
strictor nerves;  in  addition  the  conditions  under  which 


DYNAMIC  THEORIES  97 

these  important  different  sets  of  nerves  function  are 
now  known. 

DYNAMIC   THEORIES 

Muscular  Function.— Another  point  of  interest  relates 
to  the  action  of  the  muscles.  The  modes  of  action  of  the 
voluntary  muscles  and  of  the  smooth  muscles  have  been 
very  vaguely  understood.  It  is  really  surprising  that 
organs  so  simple  as  the  smooth  muscles,  simple  fusiform 
cells  united  together  into  a  fabric,  should  cause  so  much 
dispute  in  regard  to  their  mode  of  action. 

All-or-None  Principle. — The  reader,  if  he  gropes 
deeply  in  his  cortex,  will  remember  the  all-or-none  prin- 
ciple. This  is  the  fact  that  a  heart  is  practically  all  of  one 
muscle-fiber.  The  fibers  of  the  heart  are  connected  to- 
gether in  so  intimate  a  way  that  when  one  fiber  contracts, 
they  all  contract.  This  principle  is  known  as  the  "all-or- 
none"  principle.  A  physiologist  by  the  name  of  Keith 
Lucas,  in  England,  has  shown  that  probably  one  ought 
to  consider  the  voluntary  muscles  as  working  in  a  sense 
on  the  same  principle;  that  is,  Lucas  suggests  that  the 
voluntary  muscles  work  on  the  principle  of  all-or-none. 
He  postulates  that  every  voluntary  muscle  is  divided  up 
into  as  many  functional  groups  of  fibers  as  there  are 
motor  neurons  in  it ;  in  other  words,  the  muscle  fibers 
under  the  control  of  one  motor  neuron  act  on  the  prin- 
ciple of  all-or-none.  Now  this  explains  something  that 
has  long  been  a  mystery  in  physiology,  namely,  why  peo- 
ple under  conditions  of  emotional  excitement  sometimes 
have  such  an  enormous  increase  of  available  energy. 
A  hysterical  woman,  for  instance,  will  make  others  and 
herself  believe  for  years  that  she  is  paralyzed,  and  will 
lie  in  bed  in  the  house,  or  think  she  is  scarcely  able  to 
walk  across  the  room.  Suddenly  the  house  catches  fire, 
and  she  seizes  two  or  three  children  under  one  arm  and 
perhaps  in  her  haste  something  else  that  is  heavy  under 


98       RECENT  ADVANCES  IN  PHYSIOLOGY 

the  other,  runs  downstairs  and  into  the  street — and  is 
well  forever  after !  Thus  it  may  be  seen  that  under  con- 
ditions of  excitement,  which  we  do  not  yet  quite  under- 
stand, the  muscular  apparatus  is  able  to  greatly  multiply 
its  energy.  The  supposition  now  is  that  under  these 
conditions  all  these  groups  of  fibers  in  a  voluntary  muscle 
are  stimulated  simultaneously  in  some  mysterious  way 
instead  of  being  stimulated  one  by  one,  so  that  the  energy 
of  the  muscle  is  greatly  increased.  That  is  an  interesting 
point  of  a  rather  technical  nature,  a  dynamogenic  ex- 
planation. 

Stheneuphoric  Index. — Another  thing  that  has  been 
treated  recently  by  certain  writers  is  the  relation  be- 
tween good  humor  and  the  expenditure  of  energy.  It  is 
technically  called  the  stheneuphoric  index,  and  it  is  ob- 
viously the  ratio  which  exists  directly  between  joy  and 
pleasantness  and  the  expenditure  of  energy.  When  a 
man  expends  a  large  amount  of  energy  he  is  generally 
in  a  condition  of  enjoyment;  and  when  a  man  is  happy 
he  can  spend  more  energy  than  when  he  is  unhappy  and 
discontented.  This  relationship,  though  it  can  be  but 
briefly  considered  here,  is  vastly  important  in  all  skilled 
work. 

RESEARCH   ON   BLOOD   PRESSURE 

Other  work  that  has  been  done  in  the  last  few  years 
relates  to  blood  pressure  or  arterial  tension.  It  is  be- 
coming now  a  popular  fad,  as  it  has  been  for  some  years 
among  the  medical  profession.  New  discoveries  have 
been  made  and  are  being  made  daily  in  this  connection. 
At  present,  however,  the  writer  merely  wishes  to  suggest 
that  he  has  worked  out  a  method  of  making  relatively 
"continuous"  records  of  blood  pressure.  In  the  course 
of  his  work  on  the  subject  a  young  woman  doctor  sub- 
mitted herself  to  anesthesia  under  nitrous  oxid  and 
oxygen.     The  hemobarogram,  the  result  of  the  experi- 


RESEARCH  ON  BLOOD  PRESSURE 


99 


ment,  is  here  shown.  (The  heavy  line  at  110  in  the  dia- 
gram represents  the  systolic  pressure  or  110  m.  m.  of  mer- 
cury; the  heavy  line  at  the  bottom  is  the  diastolic  pres- 
sure, or  80  m.  m.,  so  that  the  space  between  the  two  heavy 
lines  is  30  m.  m.)  Under  anesthesia  the  blood  pres'sure 
was  taken  and  found  quickly  to  go  up  about  40  m.  m.    The 


ico 

150 
140 
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120 
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0     5     10     15    20    25    30    35    40    45     50    55    00    65 

Minutes 

Fig.  37. — Hemcbarogram  A  22.  Young  woman,  Forsyth  Dental  Infirmary 
for  Children.  The  twenty  millimeter  systolic  plateau  for  12  minutes  repre- 
sents the  effects  of  nitrous  oxid  given  with  a  modern  apparatus  for  mix- 
ing that  gas  with  oxygen  or  air  in  any  desired  combination.  The  peaks 
are  due  to  beginning  asphyxia  when  using  the  laughing  gas  alone;  the 
falls  representing  the  instantaneous  effect  of  applying  oxygen.  Some 
occipital  ami  frontal  headache  on  awaking.  No  lunch  taken;  no  nausea. 
Heart  rates  60,  96,  64,  60,  64,  58.  The  author  extends  his  compliments 
to  Dr.  Goette  of  Cleveland  for  her  kindness  which  allowed  the  making 
of  this  record. 


sharp  point,  or  drop,  was  made  by  the  turning-in  of 
oxygen.  It  can  be  seen  that  the  turning  in  of  oxygen  in- 
stantly reduced  the  arterial  tension.  There  is  no  danger 
of  excessive  blood  pressure  with  nitrous  oxid  when  it 
can  be  reduced  so  quickly  by  turning  pure  oxygen  into 
the  lungs.  One  level  of  lines  shows  the  normal  elevation ; 
while  those  above  the  normal  are  due  to  the  application 
of  nitrous  oxid. 


100     RECENT  ADVANCES  IN  PHYSIOLOGY 

An  interesting  curve,  or  hemobarogram,  of  the  blood- 
pressure  of  a  student  in  the  Harvard  Summer  School 
shows  beautifully  how  quick  and  strong  is  the  arterial 
"response"  to  emotional  conditions.  At  this  point  on 
the  curve  the  experimenter  suggested  that  the  subject 


140 


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Fig.  38. — Hemobarogr/m  B1 18.  Woman,  28.  During  the  twenty-fourth 
minute,  accompanying  an  imaginary  mental  pain,  the  systolic  rise  from 
97  to  111  (diastolic,  67-76)  occurred.  When  the  stimulus  ceased,  the 
systolic  fell,  but  the  diastolic  (vasoconstriction)  continued  upward;  the 
second  systolic  elevation  (100  to  112)  had  no  conscious  correlate  what- 
ever (diastolic  rise,  one  millimeter),  but  at  its  end  the  Korotkoff  sounds 
at  the  third  phase  had  wholly  gone,  the  systolic  sagged  to  110,  the  young 
woman  burst  into  tears,  and  there  was,  as  is  seen,  a  systolic  tensional 
rise  of  34  millimeters  in  five  minutes  (diastolic  at  92)  which  subsided  in 
a  curve  like  that  of  exercise-rest  in  about  eight  minutes;  but  stayed  30 
millimeters  above  the  initial  average  for  at  least  eighteen  minutes  (the 
diastolic  21  millimeters  above).  This  was  a  true  emotion  (love-disap- 
pointment) and  its  long  latency  seems  to  corroborate  the  findings  of 
Cannon  and  his  colleagues  that  increased  adrenin,  and  perhaps  dextrose, 
is  concerned  in  all  true  emotion.  The  heart  rates  ran  60,  74,  110  (esti- 
mated), 70. 


think  of  the  most  unpleasant  thing  that  had  ever  hap- 
pened to  her.  The  blood  pressure  went  up  about  15 
m.  m.  and  then  promptly  went  down  again.  But  what- 
ever the  thought,  it  obviously  started  a  real  emotion,  and 
the  blood  pressure  immediately  rose  again.     It  will  be 


120 


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70 


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Minutes 
Fig.  39. — Hemobarogram  A  14.  Woman,  23.  The  systolic  rise  of  nearly 
thirty  millimeters  in  90  seconds  or  less  from  multiplication  effort  is 
noteworthy;  also  the  slower  diastolic  rise,  typically  less  in  extent, 
and  the  quicker  diastolic  downfall  alter  unpleasantness,  with  a  fall  eleven 
millimeters  below  the  previous  mean.  The  heart  was  the  typical  irregular 
heart  to  be  expected  from  playing  basketball  at  15  years.  The  heart 
rate  \aried  between  92  and  96  at  first  and  the  observation  stopped  with 
it  at  85. 


Fig.  40. — Hemobarogram  D'j  3.  Woman,  23.  Note  the  40  millimeter  fall  in 
the  systolic  series  at  the  beginning  of  the  thirty-eighth  minute;  the  stimu- 
lus (mental  condition)  being  one  of  imaginary  fatigue  and  relaxation  fol- 
lowing imaginary  active  exercise.  The  diastolic  tension  maintained  its 
degree  to  an  unusual  extent.     The  heart  rate  varied  from  80  to  73. 

101 


102     RECENT  ADVANCES  IN  PHYSIOLOGY 

observed  that  the  systolic  and  diastolic  blood  pressure 
stayed  up  this  time  for  twenty  or  thirty  minutes. 

From  these  it  will  be  observed  how  greatly  and  how 
quickly  unpleasant  emotions  raise  the  blood  pressure. 
On  the  other  hand,  pleasant  states,  so  long  as  they  be  not 
allowed  to  shock  in  any  way,  and  as  long  as  they  come 
on  gradually,  lower  the  blood  pressure.  Some  of  these 
charts  represent  three  or  four  hours'  work.  One  experi- 
ment, for  example,  took  about  an  hour  and  a  half,  and 
another  hour  and  a  half  to  work  out  the  curves. 

The  writer  has  enumerated  the  most  important  recent 
discoveries  along  physiological  lines.  Many  of  these  are 
as  yet  merely  theoretical,  but  earnest  workers  will  watch 
and  hope,  for  the  future  is  still  before  them. 


CHAPTER    III 

DENTAL   PATHOLOGY    AND    BACTERIOLOGY,    CHEMISTRY, 
PHYSICS  AND  METALLURGY 

Percy  R.  Howe,  A.  B.,  D.  D.  S. 

PYORRHEA 

Organisms  Found  in  Pyorrhea.— The  subject  of  pyor- 
rhea and  of  the  dental  abscess  has  of  late  attracted  a 
great  deal  of  attention,  because  the  idea  has  been  held  by 
some  that  these  pathological  conditions  are  responsible 
for  a  great  many  systemic  diseases.  This  view  has  been 
pretty  thoroughly  incorporated  into  the  mind  of  the  med- 
ical profession,  even  though  recent  experiments  have 
tended  to  refute  this  theory  to  a  certain  degree.  For  this 
reason  pyorrhea  assumes  an  unusual  importance,  and  its 
etiology  should  be  understood.  Various  opinions  have 
been  advanced  as  to  its  cause.  By  some  it  is  thought  to 
be  a  bacterial  disease.  The  streptococci,  the  staphylo- 
cocci, the  micrococci  catarrhalis,  the  pneumococci,  are 
various  organisms  that  have  been  held  responsible  for 
this  condition.  The  reason  for  believing  that  these  mi- 
croorganisms are  a  cause  of  pyorrhea  has  been  based 
merely  upon  their  presence  in  the  affected  part. 

Noguchi  has  isolated  and  raised  in  pure  culture  two 
spirochaetae  from  pyorrhea,  viz.:  Treponema  mucosum 
and  Treponema  microdentium.  These  are  strict  anaer- 
obes, mucin  formers,  and  produce  the  odor  characteris- 
tic of  the  affection.  Vincenti  has  shown  the  presence  of 
Bacillus  fusiformis  in  pyorrhea. 

But  no  one  has  yet  been  able  to  produce  pyorrhea  by 

103 


104  DENTAL  PATHOLOGY  AND  BACTERIOLOGY 

the  injection  of  any  of  these  microorganisms  either  in 
pure  culture  or  in  mixed. 

On  the  other  hand,  the  writer  has  produced  in  guinea 
pigs,  by  diet,  a  condition  that  resembles  pyorrhea.  The 
teeth  became  loose,  the  gums  bled,  and  in  some  cases  pus 
formed.  This  is  a  condition  that  others  have  produced  in 
studies  upon  scurvy.  The  impacted  cecum  has  appar- 
ently been  the  center  from  which  the  trouble  here  origi- 
nated, for  cathartics  have  removed  the  trouble,  and  the 
teeth  have  tightened. 

The  important  point  here  is  that  the  infection  is  sec- 
ondary to  an  anomalous  metabolic  condition.  Pyorrhea 
may  be  produced  locally  by  irritation,  by  trauma,  and 
by  other  causes.  The  tissue  resistance  must  first  be 
broken  down,  and  then  the  infection  follows. 

The  treatment  is  surgical  and  hygienic  locally  with 
attention  to  the  correction  of  dietetic  and  metabolic 
irregularities. 

Nature  of  Tartar.— Another  thing  of  interest  in  this 
connection  is  tartar,  its  nature,  and  mode  of  formation. 
The  writer  has  found  by  analysis  that  tartar  consists  of 
carbonate  and  phosphate  of  calcium.  He  has  not,  in  about 
fifty  analyses,  found  urates  present,  as  many  have 
claimed.  Analyses  show  that  the  phosphate  of  calcium 
forms  about  85  per  cent  of  the  tartar,  while  the  carbonate 
of  calcium  is  present  in  about  15  per  cent.  The  principles 
of  pathological  calcification  laid  down  by  Dr.  H.  Gideon 
Wells  in  his  Harvey  Lecture  are  in  the  main  applicable 
here  in  such  calcific  deposition  as  occurs  in  tartar.  Cal- 
cium is  held  in  the  blood  and  in  the  saliva  in  from  two  to 
four  times  its  water  solubility.  The  C02  and  the  col- 
loids accomplish  this.  Any  alteration  in  the  colloids,  or 
the  escape  or  decrease  of  C02  promotes  tartar  formation. 
An  excess  of  calcium  in  the  bodily  fluids  acts  in  the 
same  way. 

Tho  stroma  in  which  the  inorganic  constituents  are  laid 
down  are  the  degenerate  tissue  of  the  peridental  mem- 


PYORRHEA  105 

brane,  in  the  case  of  the  so-called  serumal  tartar,  and  pre- 
cipitated mucin  in  the  salivary  calculus. 

Tartar  formation  is  in  the  main  a  systemic  affection. 

Amebic  Theory  of  Pyorrhea. — There  is  another  theory 
which  it  is  well  to  know  something  about,  and  that  is  the 
theory  that  amebae  cause  pyorrhea.  Roughly  speaking, 
there  are  three  kinds  of  amebae  that  inhabit  the  human 
system :  first,  the  Endamoeba  buccalis  which  we  consider 
harmless;  second,  the  Amoeba  coli,  also  harmless;  and 
third,  the  Amoeba  histolytica.  This  last  is  the  cause  of 
tropical  dysentery,  and  it  is  because  of  this  that  the 
Amoeba  buccalis  has  been  considered  parasitic  by  some. 
The  Amoeba  buccalis  is  a  very  interesting  organism,  and 
can  be  obtained  from  almost  any  mouth.  An  examination 
of  the  mouths  of  the  young  patients  in  the  Dental  Infirm- 
ary showed  an  abundance  of  amebae.  The  mouth  of  one 
of  the  athletes  of  Harvard,  one  of  the  finest  specimens 
of  men  who  had  just  broken  a  record,  was  examined,  and 
plenty  of  amebae  were  found  in  it.  The  amebae  do  not 
feed  on  tissue.  They  feed  upon  the  dead  bacteria,  and 
cleanse  the  mouth  as  if  it  wTere  a  pool  of  dirty  water. 
There  is  no  evidence  that  the  amebae  of  the  mouth  have 
anything  to  do  with  pyorrhea,  and  this  is  very  generally 
understood  now. 

Pyorrhea  and  the  dental  abscess  have  been  considered 
foci  of  infection,  and  on  the  strength  of  this  theory  many 
useful  teeth  have  been  needlessly  extracted.  Teeth  are 
very  necessary  to  the  army  men.  It  is  the  opinion  of 
the  writer  that  the  theory  of  the  foci  of  infection,  par- 
ticularly with  respect  to  the  teeth,  needs  further  study 
before  it  is  made  the  basis  of  practice. 

Universal  Prevalence  of  Microorganisms.  —Man 
breathes,  eats  and  drinks  microorganisms.  There  is  no 
such  thing  as  a  sterile  mouth,  nor  are  even  mammals 
sterile.  Nature  has  not  intended  that  they  should  be. 
Microorganisms  enter  the  circulation  from  time  to  time 
through  the  nasal  mucosa  and  through  the  intestinal  wall. 


106  DENTAL  PATHOLOGY  AND  BACTERIOLOGY 

Examinations  of  the  internal  organs  of  animals  show  that 
there  is  an  internal  microbic  flora  as  well  as  an  external. 
Therefore,  "point  of  entrance"  means  but  little.  It  is  in 
the  cellular  activity  of  tissue  and  of  the  blood  that  the 
defense  against  microbic  invasion  lies,  and  it  is  manifest 
in  a  specific  manner  in  the  sera  of  animals.  It  is  not  so 
much  the  point  of  entrance  as  the  question  of  resistance 
that  concerns  us. 

Streptococcus  Viridans  Infection. — Why  of  all  the 
microorganisms  of  abscess  and  pyorrhea  the  Streptococ- 
cus viridans  should  be  fastened  upon  as  the  cause  of 
many  maladies  attributed  to  these  conditions  the  writer 
does  not  know.  It  is  certainly  one  of  the  least  virulent. 
Massive  doses  are  injected  to  produce  any  effect,  and  an 
animal  is  tolerant  of  exceedingly  large  amounts.  From 
one  to  twenty-five  c.c.  of  viridans  in  suspension  may  be 
injected  into  an  animal  without  serious  consequences, 
while  .000001  of  a  c.c.  of  a  virulent  streptococcus  will  pro- 
duce septicemia  and  death.  Therefore,  from  the  stand- 
point of  virulence,  one  need  have  no  grave  fear  of  the 
viridans.  Neither  pyorrhea  nor  dental  abscess  can  be 
produced  by  the  injection  of  these  microorganisms.  On 
the  other  hand,  as  the  writer  has  stated  above,  by  lower- 
ing the  resistance  of  an  animal  by  dietary  means,  the 
teeth  loosen,  and  infection  of  the  tissue  follows.  A  tooth 
struck  by  a  blow  shows  subsequent  infection  of  the  pulp, 
because  the  circulation  is  injured,  the  resistance  of  the 
tissue  is  lowered,  and  without  any  external  communi- 
cation the  pulp  becomes  the  seat  of  infection.  So  it  is 
with  the  tonsil,  which  histologically  is  a  lymph  gland. 
When  by  stress  of  work  upon  it  its  tissue  breaks  down, 
it  also  becomes  the  seat  of  infection.  Much  other  evi- 
dence might  be  brought  forward  to  support  the  idea  that 
this  type  of  infection  is  secondary. 

Importance  of  Resistance.— In  such  cases  as  pyorrhea 
and  abscess,  the  first  thing  to  understand  is  why  and 
how  the  first  infection  occurs,  before  we  can  go  on  to  in- 


PYORRHEA  107 

telligently  explain  any  supplementary  or  coincident  trou- 
ble. After  clearing  up  certain  extensive  cases  of  pyor- 
rhea, improvement  is  at  times  seen  in  a  remote  pathologi- 
cal condition.  If  this  secondary  trouble  has  proceeded 
or  originated  from  the  pyorrhea,  it  has  now  become  an 
established  thing.  It  has  become  an  independent  process. 
What  then  has  the  removal  of  the  primary  foci  to  do  with 
it?  There  is  but  one  explanation  for  the  improvement 
that  may  follow.  It  is  that  a  load  is  taken  of  the  resist- 
ance. Resistance,  general  or  local,  is  the  keynote  of  such 
bacterial  invasions. 

Focal  Infection.— What  is  there  in  the  pathology  of 
the  blind  abscess  to  indicate  a  tendency  to  bacterial  dif- 
fusion! The  bacteria  selected  as  the  basis  of  the  theory 
are  the  most  innocent.  They  are  types  such  as  Pasteur 
used  in  his  early  studies  upon  immunity.  Examination 
of  such  a  root  end  shows  a  hyaline  condition,  an  oblitera- 
tion of  dentinal  tubules,  of  organic  matter.  It  is  a  protec- 
tive effort  on  nature's  part  far  superior  to  that  effected 
by  any  mechanical  procedure.  Therefore,  so  minor  and 
so  small  a  thing  as  a  dental  abscess,  with  all  its  protec- 
tive and  walled-off  structures,  with  all  the  forces  of  im- 
munity between  it  and  danger,  cannot  be  the  cause  of 
all  the  ills  that  theorists  attribute  to  it. 

I  am,  of  course,  heartily  in  favor  of  cleaning  up  any 
oral  infective  condition.  That  is  our  daily  business.  That 
is  the  sum  total  of  dental  practice,  but  it  is  outside  the 
topic  of  discussion. 

The  light  and  dark  of  the  roentgenograms  are  not  to 
be  taken  as  deciding  factors  per  se;  they  are  valuable 
adjuncts,  but  clinical  symptoms  must  first  be  considered 
before  forging  ahead  too  extensively  in  these  matters. 
Much  harm  has  already  resulted  from  laying  too  much 
stress  upon  the  principle  of  the  dental  primary  foci ;  too 
many  serviceable  teeth  have  been  removed  on  account  of 
it.  We  need  to  take  a  broader  view  of  this  topic.  We 
must  not  base  practice  upon  the  exception.    It  seems  to 


108  DENTAL  PATHOLOGY  AND  BACTERIOLOGY 

me  that  the  proofs  offered  as  a  basis  for  the  exploitation 
of  this  theory  are  not  sufficiently  complete  for  us  to  adopt 
them  as  a  basis  of  practice,  nor  for  allowing  them  to  make 
a  scapegoat  of  dental  affections  for  the  many  but  too 
little  understood  bodily  ills. 


BACTERIOLOGY  OF  DENTAL  CARIES 

The  literature  upon  the  mycology  of  the  mouth  is  volu- 
minous, yet  it  contains  no  work  upon  the  bacteriology  of 
dental  caries  that  meets  modern  biological  requirements. 

Miller's  Work  on  Caries.— Miller,  in  1880-90,  carried 
out  the  work  that  is  most  familiar  to  dentists.  He  placed 
teeth  in  a  fermenting  mixture  of  bread  and  saliva,  renew- 
ing this  from  time  to  time  in  order  that  it  might  not  grow 
alkaline,  and  he  succeeded  "after  three  months  in  pro- 
ducing effects  upon  tooth  sections  which  could  not  be 
told  either  microscopically  or  macroscopically  from  true 
caries."  He  then  demonstrated  by  zinc  crystallization 
that  such  a  fermenting  mixture  produced  lactic  acid  and 
upon  this  evidence  he  originated  the  lactic  acid  theory  of 
caries. 

Now,  the  bacteria  that  have  the  property  of  fermenting 
carbohydrates  are  legion.  Miller  had  no  thought  of  bac- 
terial specificity  in  this  action.  He  described  a  few  oral 
bacteria  such  as  Leptothrix  innominata,  B.  buccalis 
maximus,  Jodococcus  vaginatus,  Spirillum  sputigenum, 
Spirochaeta  dentium;  but  he  himself  says  that  "this 
bacteriological  study  upon  caries  has  not  been  sufficiently 
extensive  or  conclusive"  to  warrant  being  incorporated 
into  his  book.  His  work  was  done  30  years  ago,  and,  as 
has  been  said,  he  paid  no  attention  to  any  specific  micro- 
organism. The  idea  he  had  in  his  mind  all  the  time  was 
simply  the  fermentation  of  food  materials,  sugars  and 
starches,  particularly  starches. 

He  states  that  this  theory  is  only  a  part  of  the  carious 


BACTERIOLOGY  OF  DENTAL  CARIES      109 

process.  The  lactic  acid  of  fermentation  inaugurates  the 
process.  The  work  must  be  completed  by  proteolytic 
bacteria,  these  having  the  property  of  completing  the 
destruction  of  the  tooth  substance  after  it  has  been  de- 
calcified.   These  proteolytic  bacteria  are  unknown  to  him. 

Work  of  Goadby.— There  have  been  other  workers 
upon  this  subject,  the  most  important  of  whom  is  Goadby. 
His  work  is  more  modern  and  more  in  keeping  with  mod- 
ern ideas  as  to  the  bacterial  requirements.  Goadby,  in 
1902-3,  studied  the  microorganisms  of  the  superficial  and 
the  deep  layers  of  decay.  He  classifies  these  bacteria  as 
acid  formers  and  liquefiers;  the  acid  formers  being  the 
ones  that  precede  the  active  decay,  and  the  liquefiers,  hav- 
ing the' property  of  liquefying  gelatine,  indicate  that  they 
had  the  property  of  dissolving  the  organic  structure  of 
the  tooth.  Goadby  also  found  that  in  the  deeper  layers  of 
decay  a  smaller  variety  of  bacteria  exists.  The  deeper  he 
went,  the  fewer  bacteria  he  found.  In  eighteen  cases  he 
constantly  found  Streptococcus  brevis  and  B.  necroden- 
talis  (as  he  calls  it)  and  nothing  else.  In  another  part  of 
his  work  he  adds  to  these  staphylococci.  In  the  super- 
ficial decay  he  finds  other  things :- — B.  mesentericus,  B. 
furvus,  B.  plexiformis,  both  Staphylococcus  aureus  and 
albus,  sarcinae  and  some  other  forms.  He  lays  particular 
stress  on  the  streptococci  and  staphylococci  in  this 
connection.  There  are  other  workers  who  agree  with  him 
in  this  latter  finding. 

It  should  be  stated  tnat  a  great  many  of  the  theories 
that  have  arisen,  or  descriptions  of  bacteria  that  have 
arisen  in  connection  with  dental  decay,  have  been  arrived 
at  simply  by  taking  a  little  of  the  bacterial  mass  off  tooth 
surfaces,  smearing  it  out  and  examining  it.  Pickerel, 
in  his  work  of  making  some  comparative  tests  among 
the  native  tribes  in  Australia,  made  his  examina- 
tion solely  by  smears,  and  arrived  at  his  conclusions  from 
his  interpretation  of  them.  One  cannot  get  a  very  deep 
knowledge  of  bacteria  by  simply  looking  at  microorgan- 


1 10  DENTAL  PATHOLOGY  AND  BACTERIOLOGY 

isms.     They  must  be  studied  culturally  in  pure  culture 
and  subjected  to  biochemical  and  other  tests. 

Kligler's  Work.— Recently  Kligler  studied  the  micro- 
organisms of  the  mouth.  11  is  work  was  done  in  1915. 
He  collected  material  from  tooth  surfaces,  and  made  a 
bacterial  count  of  the  microorganisms  from  the  mouths 
of  immunes  and  also  from  the  mouths  of  those  who  had 
prolific  decay.  He  arrived  at  the  conclusion  that  the 
streptococci  predominated  in  mouths  free  from  decay,  but 
that,  as  decay  proceeded,  this  character  of  the  oral  flora 
wTas  changed  from  a  streptococcal  to  an  acidic  rod  and  a 
thread  flora.  Unfortunately  the  immunes  were  limited  in 
number.  From  a  few  cases  of  immunes,  and  of  adults  at 
that,  one  cannot  arrive  at  anything  very  conclusive,  but 
it  is  probable  that  on  the  whole  Kliggler  was  correct. 
The  research  department  at  the  Forsyth  Dental  Infirm- 
ary has  done  the  same  kind  of  work  upon  an  extensive 
scale,  and  the  work  taken  as  a  whole  agrees  with  his. 
From  what  has  been  said  it  can  be  seen  that  there  is  no 
agreement,  nor  has  work  of  much  account  from  the  bac- 
teriological standpoint  been  done  upon  caries.  At  the 
Forsyth  Infirmary  a  careful  study  of  caries  has  been 
made.  In  order  to  be  sure  that  the  proper  flora  were 
under  investigation  the  research  department  selected 
children  of  nearly  the  same  age,  the  same  tooth  or 
teeth,  the  sixth  and  the  twelfth  year  molars,  where  decay 
was  active,  being  chosen  for  study.  It  can  be  seen  that 
examination  of  the  decayed  tooth  in  an  adult  might  not 
always  give  proper  results,  because  one  does  not  know 
whether  or  not  the  caries  is  active.  The  decay  may  have 
stopped  and  a  different  flora  may  be  growing  in  the  cavity 
that  may  not  have  anything  to  do  with  decay.  It  may 
simply  live  there  as  an  incidental  invader.  Before  study 
was  begun  it  vas  thought  that  the  microorganisms  in  a 
decayed  tooth  would  be  very  varied ;  therefore  an  at- 
tempt was  made  to  get  at  this  matter  in  three  different 
ways. 


BACTERIOLOGY  OF  DENTAL  CARIES      111 

Bacteriological  Experiments.— First,  inert  fillings  were 
inserted  over  the  decay.  These  were  allowed  to  stay  in 
place  three  months,  with  the  idea  that  the  microorgan- 
isms that  were  most  at  home  in  the  tooth  and  most  active 
and  responsible  for  decay  would  live,  while  those  that 
were  incidental  invaders  would  die  off.  After  three 
months  these  fillings  were  removed,  and  the  carious  ma- 
terial cultured. 

In  another  series  of  cases,  and  with  the  same  prin- 
ciple in  view,  cement  fillings,  with  slight  antiseptic 
properties,  were  put  in.  These  were  not  left  for  so  long 
a  time,  the  idea  being  that  the  antiseptic  would  act  upon 
the  weaker  and  more  incidental  bacteria  and  would  kill 
them,  while  the  more  hardy  organisms  and  those  which 
had  the  best  hold  upon  life  would  in  all  probability  sur- 
vive the  antiseptic  properties. 

Again  in  the  third  condition  the  flora  was  examined 
from  the  open  carious  tooth. 

Moro-Tissier  Group  of  Organisms.— It  was  soon  seen 
that  comparatively  few  organisms  were  to  be  reckoned 
with.  It  was  evident  from  observation  that  the  constant 
and  predominating  flora  of  dental  caries  was  the  closely 
allied  group  of  microorganisms  described  by  Moro,  Tis- 
sier  and  others.  These  were  found  in  all  the  cases  of 
decayed  teeth  examined  and  were  the  prevailing  bacteria. 
In  cases  that  had  been  under  fillings  for  three  months, 
and  under  fillings  with  slight  antiseptic  properties  for  a 
shorter  time,  no  other  microorganisms  were  found.  In 
the  flora  from  the  open  teeth  it  was  found  that  in  about 
40  per  cent  of  the  cases  there  was  nothing  else  present ; 
that  is,  on  the  media  used: — agar,  glucose-agar,  blood 
serum  and  bouillon.  These  microdrganisms  were  cul- 
tured aerobically  and  anaerobically. 

In  the  first  class  of  cases,  after  taking  out  the  amalgam, 
using  aseptic  precautions,  the  decay  was  removed  in  three 
layers.  We  took  off  a  top  layer,  taking  several  little  bits 
from  this  upper  area  and  planting  them  on  the  various 


1 1 2  DENTAL  PATHOLOGY  AND  BACTERIOLOGY 

media  just  mentioned.  Then  from  the  middle  layer 
the  same  thing  was  done.  Next,  a  third  or  deep  layer 
was  removed,  after  which  the  deep  dentine  was  studied. 
This  small  group  of  microorganisms,  and  nothing  else, 
was  found  in  every  case.  They,  and  nothing  else,  were 
found  under  the  antiseptic  fillings  and  cements.  They, 
and  nothing  else,  were  found  in  40  per  cent,  in  round 
numbers,  of  the  open  tooth  cavities. 

In  some  of  the  open  carious  teeth  other  things  were 
found;  yeast  for  one  thing,  which  is  very  common  in  the 
mouth  but  is  not  often  mentioned.  Micrococcus  catarrhal- 
is,  staphylococci,  streptococci,  and  other  bacteria  were 
found,  but  there  was  no  regularity  in  their  appearance. 
Some  member  of  the  Moro-Tissier  species  was  always 
present.  This  group  is  a  known  group.  It  has  been  stud- 
ied, fortunately,  by  some  very  able  men,  but  it  has  never 
been  found  in  the  mouth  before.  The  natural  place  in 
which  it  has  been  studied  has  been  the  intestine  of  a 
nursing  infant ;  in  fact,  it  forms  the  dominant  flora  of  a 
nursing  infant's  intestinal  content,  which  is  very  acid. 
There  is  the  home  of  it,  so  far  as  is  known,  until  solid 
food  begins  to  be  taken,  when  it  gradually  gives  way  to 
other  bacteria.    Our  experiments  found  it  in  the  mouth. 

This  group  of  organisms  has  been  called  the  Moro-Tis- 
sier group.  Kendall,  Calm,  and  a  great  many  other  work- 
ers have  studied  this  species.  This  flora  possesses  two 
or  three  very  important  characteristics.  One  is  that  it  is 
a  very  high  acid  producer, — the  cultures  producing  about 
14  per  cent  normal  acid, — much  higher  than  ordinary 
organisms.  Not  only  that,  but  it  is  characterized  as  a 
highly  pleomorphic  group.  One  of  these  organisms  has 
been  treated  by  Noguchi  in  a  most  interesting  manner, 
in  an  article  in  which  he  gives  an  account  of  his  study 
upon  B.  bifidus.  He  says  that  he  was  "able  to  show  B. 
bifidus  to  be  an  anaerobic  phase  of  an  aerobic  sporagen- 
ous  organism  belonging  to  the  subtiloid  group  and  closely 


jy 


B.  bifidus 


B.   [X] 


>fr 


P 


B.  bifidus.     Staphylococcus  form 


\ 


¥• 


/ 


M 


B.  bifidus.     Streptococcal  form 


B.  bifidus.     Spore 


Fig.  41. — Microorganisms  pkcm  Dental  Caries,  B.     Bifidus  and  B.  X. 

113 


114  DENTAL  PATHOLOGY  AND  BACTERIOLOGY 

resembling,  especially  morphologically  and  biologically, 
B.  mesentericns  fuscus." 

Moro's  acidophilus — in  studying  these  organisms  that 
term  should  be  remembered — has  been  found  in  the 
mouth,  but  there  is  no  previous  record  of  B.  bifidus  hav- 
ing been  found  there.  From  the  examination  of  about  25 
specimens  of  deep  dentine  which  are  being  studied  now  at 
the  Infirmary  B.  bifidus  was  found  in  nearly  every  case. 
In  some  of  the  teeth  the  operator  had  excavated  every- 
thing and  no  growth  was  obtainable.  These  microorgan- 
isms possess  the  property  of  inaugurating  decay  in  a 
much  greater  degree  than  any  other  organism.  They  are 
the  dominant  flora, — the  only  flora  of  tooth  decay  that  is 
constant.  It  cannot  be  stated  that  they  are  the  cause  of 
caries.  There  are  many  other  factors  that  may  enter 
into  this,  but  their  constant  presence,  their  acid-forming 
and  acid-tolerating  properties  are  interesting. 

A  glance  at  the  cuts  and  descriptions  of  the  few  micro- 
organisms that  Dr.  Miller's  work  contains,  shows  that 
lie  had  seen  these  microorganisms,  but  he  did  not  study 
them  morphologically  and  did  not  identify  them.  The 
same  is  true  of  Goadby's  work.  His  B.  plexiformis  and 
micrococcus  dentalis  are  undoubtedly  organisms  of  this 
Moro-Tissier  group  that  we  have  termed  B.  X.  in  our 
work,  and  so  it  is  with  others  that  he  describes. 

Summary. — It  is  the  theory  of  Dr.  Miller  that  is  known 
and  taught  and  therefore  must  be  the  basis  for  exam- 
ination work.  But  while  Miller  has  done  astonish- 
ingly well  for  his  time,  still  much  remains  to  be  worked 
out. 

A  brief  account  has  been  given  of  the  studies  upon 
the  subject  here.  Eighty  cases  have  been  examined. 
Uniform  conditions  have  been  sought  and  a  constant 
flora  in  caries  has  been  found  and  identified;  its 
sugar-fermenting  properties,  its  high  acid-forming  and 
high  acid-tolerating  properties  demonstrated,  and  that  it 
overgrows  other  types  in  laboratory  media  is  proven. 


SILVER  IMPREGNATION  OF  CANALS      115 

These  are  interesting  facts  for  those  who  are  dealing 
continually  with  the  repair  of  the  carious  dental  process. 
In  this  connection  it  would  be  well  to  speak  of  a  few 
things  that  may  be  serviceable  in  practice. 

Sterilization  of  Cavities.— Cavities,  as  they  are  pre- 
pared, are  very  rarely  sterile.  This  is  on  account  of  the 
depth  of  action  of  caries.  It  is  not  practical  to  sterilize 
any  cavity  by  the  burr  except  the  most  superficial.  Bac- 
teria have  been  shown  to  be  alive  under  fillings  after  six 
months,  and  it  is  believed  that  the  attempt  should  be 
made  to  destroy  them  and  that  work  should  be  carried  on 
upon  surgical  principles. 

A  tooth  cavity  can  be  made  sterile  by  drying  it  for  5 
minutes  with  70  per  cent  alcohol  if  the  cavity  has  been 
well  excavated.  A  very  effective  way  of  sterilizing  the 
decay  in  posterior  teeth  is  by  using  an  ammoniacal  solu- 
tion of  silver  nitrate  and  reducing  the  metallic  silver  by  a 
solution  of  formalin.  This  produces  sterility  and  at  the 
same  time  impregnates  the  pathological  tissue  with  a 
metal.  The  formula  is  given  below.  Copper  cements 
have  slight  antiseptic  properties.  From  the  bacteriology 
of  caries  alkaline  washes  are  indicated.  Physiological 
salt  solution  is  recommended  for  ordinary  use. 


METALLIC  SILVER  IMPREGNATION  OF  CANALS 

Some  very  interesting  histological  work  is  now  being 
carried  out  in  connection  with  six-year  molars,  many  of 
which  are  abscessed  teeth.  In  a  badly  abscessed  root  it 
will  be  seen  that  there  are  transparent  areas.  The  ab- 
scessed condition  affects  the  structure  of  the  teeth.  The 
first  step  in  the  treatment  of  abscessed  teeth  is  complete 
sterilization  of  the  tooth  structure  with  a  strong  solution 
of  silver  nitrate  and  subsequent  impregnation  of  the 
canals  with  it.     The  silver  solution  is  simply  pumped 


116  DENTAL  PATHOLOGY  AND  BACTERIOLOGY 

down  into  the  roots.     Two  solutions  are  necessary  for 
this  treatment,  viz. : 

I.     35  per  cent  nitrate  of  silver  J  :J  .    /Ct0ni . 

1  [J/,  ammonia  (28  %) 

II.     25  per  cent  formalin 

Method  of  Use.— This  can  be  pumped  through  the  end 
of  the  root,  if  necessary,  but  only  in  abscesses.  In  using; 
these  solutions  the  nitrate  of  silver  is  put  in  first,  using 
care  not  to  get  it  on  the  +;ssues,  and  the  root  of  the  tooth 


Fig.  42. — Effect  of  Abscessed  Condition  on  Tooth  Structure. 

is  pumped  full,  and  then  one  drop  of  the  formalin  solu- 
tion is  injected.  Actual  sterility  throughout  the  tooth 
follows  this  method.  The  illustrations  show  the  tooth 
alterations  that  occur  in  abcessed  conditions  and  the  way 
in  which  they  are  impregnated  by  the  silver.  The  black 
discoloration  is  just  silver  and  nothing  else.  This  treat- 
ment will  be  found  to  cure  an  abscess  quicker  than  any- 
thing else.  There  is  a  preparation  that  will  take  that 
silver  off  the  teeth,  but  it  is  very  poisonous  and  must 
be  handled  with  great  care.  It  must  be  stated  that  this 
treatment  is  still  in  the  experimental  stage,  but  thus  far 
it  seems  to  be  very  effective.  In  employing  the  treat- 
ment just  an  ordinary  broach  is  used.    The  preparation 


SILVER  IMPREGNATION  OF  CANALS      117 

cannot  be  used  on  the  front  teeth,  because  it  would  dis- 
color them,  but  perhaps  by  and  by  a  way  of  doing  that 
will  be  found.  As  has  been  stated  this  process  is  still  in 
the  experimental  stage,  but  it  is  a  very  good  method. 
X-rays  have  been  taken  of  some  of  these  teeth  and  they 


Fig.  43. — Teeth  After  Treatment  with  Metallic  Silver  Impregnation. 


show  up  very  well.  A  good  many  practitioners  are  rely- 
ing entirely  on  the  X-ray.  In  conclusion  it  may  be  said 
that  the  X-ray  is  a  valuable  thing,  but  there  are  a  num- 
ber of  things  it  cannot  do.  Clinical  evidence  must  be 
considered  first  in  studying  these  interpretations. 


CHAPTER  IV 

PHARMACOLOGY 

Fkank  G.  Wheatley,  M.  D. 

ACTION  OF  DRUGS 

The  relation  between  pharmacology  and  the  general 
education  of  the  physician  and  dentist  is  no  doubt  appar- 
ent. A  study  of  the  subject  presupposes  a  knowledge  of 
anatomy,  a  knowledge  of  physiology,  a  knowledge  of 
chemistry,  and  a  knowledge  of  pathology. 

The  importance  of  some  knowledge  of  the  subjects  dis- 
cussed in  pharmacology  will  appeal  to  every  one.  It  is 
obviously  desirable  to  know  something  about  some  of 
the  agents  that  are  included  in  the  lists  of  materials  which 
we  know  as  pharmaceutical  agents  or  drugs.  However, 
the  tendency  with  modern  medicine  and  modern  dentistry 
is  to  steer  away  from  the  use  of  these  agents  for  the  treat- 
ment of  pathological  conditions  and  to  depend  upon  sur- 
gical procedure,  and  the  curing,  healing  power  of  nature, 
with  the  surrounding  hygienic  conditions,  to  effect  our 
cures.  So  that  one  in  talking  about  this  subject  is  facing 
"therapeutical  nihilism." 

General  Effects  of  Drug's.— But  for  all  that  drugs  can 
never  be  wholly  eliminated  from  medical  practice,  for 
they  can  do  what  neither  surgery  nor  nature  can  accom- 
plish. With  a  drug,  perspiration  can  be  produced;  ex- 
pectorations can  be  modified;  the  secretion  of  the  res- 
piratory tract  can  be  affected, — if  it  is  excessive  it  can  be 
checked,   if   insufficient   it   can   be   increased;   vomiting 

118 


ACTION  OF  DRUGS  119 

can  be  produced ;  the  chemical  character  of  the  urine  can 
be  changed  with  drugs,  an  alkaline  urine  to  acid,  an  acid  to 
an  alkaline  urine  by  the  proper  drug  administration;  the 
circulation  of  the  blood  can  be  affected,  the  rate  and 
force  of  the  pulse  increased  or  decreased,  by  the  adminis- 
tration of  drugs;  catharsis,  or  free  movement  of  the 
bowels,  can  be  produced;  the  respiratory  function  can 
be  affected, — making  a  man  breathe  more  forcibly,  or 
more  rapidly,  by  the  administration  of  drugs;  a  man's 
digestion  can  be  affected, — the  digestive  function  stimu- 
lated so  that  when  food  enters  the  stomach  it  is  more 
promptly  and  efficiently  acted  upon  or  digested ;  the  char- 
acter of  the  blood  can  be  changed,  actually  increasing 
the  number  of  red  blood  corpuscles  (and  this  can  be 
demonstrated  by  actual  count),  by  the  administration 
of  drugs;  temperature  can  be  lowered;  pain  can  be  re- 
lieved ;  anesthesia  can  be  produced, — general  anesthesia, 
or  unconsciousness  accompanied  by  insensibility,  or  local 
anesthesia,  which  does  not  affect  the  consciousness  but 
only  sensibility  of  the  part  involved.  Those  two  func- 
tions, those  two  things,  that  can  be  done  with  drugs, — 
the  control  of  neuralgia  and  the  production  of  anesthesia, 
— are  extremely  important  as  bearing  upon  the  special 
work  of  dentists.  Then  there  are  certain  antitoxins  with 
which  the  system  can  be  so  fortified  that  it  will  deal  more 
directly  and  forcibly  with  the  cause  of  disease. 

Physical  Therapeutics.— Besides  drugs  there  are  the  so- 
called  physical  therapeutical  agents,  like  heat,  cold  and 
massage ;  so  that  there  are  a  good  many  things  that  can 
be  done  to  the  human  body  that  it  may  be  desired  to  do 
by  the  means  of  drugs  or  through  therapeutic  agents. 

If  drugs  can  do  so  much,  then  surely  the  dentist  does 
not  waste  his  time  in  acquiring  a  general  knowledge  of 
this  subject.  In  fact,  too  many  physicians,  as  well  as 
dentists,  are  apt  to  be  influenced  by  the  many  new  anti- 
drug theories  in  vogue  at  the  present  time. 


1 20  PHARMACOLOGY 


SCHOOLS  OF  THERAPY 


Here  a  few  words  may  be  said  about  a  subject  which 
physicians  do  not  like  to  talk  about  very  well,  and  which 
does  not  bother  the  dentist  very  much,  and  that  is  the 
various  schools  of  therapeutics.  It  would  seem  silly  to 
talk  about  the  kind  of  anatomy,  physiology,  chemis- 
try, or  surgery  that  a  man  is  to  study.  But  when  one 
comes  to  therapeutics  one  finds  that  there  have  grown  up, 
perhaps  rather  unfortunately,  various  schools  of  ther- 
apeutics. It  has  always  been  so,  since  the  history  of 
medicine  began.  Some  particular  sect  has  claimed  that 
it  has  discovered  the  fundamental  facts  in  regard  to 
therapeutics  and  that  if  one  should  base  all  his  therapeu- 
tics on  those  certain  fundamental  facts  he  would  have 
a  system  of  therapeutics  that  would  be  all  to  be  desired. 
Now,  the  therapeutics  here  presented  are  not  based  on 
any  particular  system,  dictum,  or  preconceived  theory. 
What  are  they,  then?  This  theory  of  therapeutics  is 
based  on  the  known  action  of  agents  on  the  course  and 
cause  of  disease.  It  will  be  asked,  "What  is  meant  by 
the  knoivn  action?  Who  knows  the  action?"  By  that 
is  meant  that  one  must  have,  under  the  present  condi- 
tions, two  kinds  of  therapeutics,  first,  an  empirical  sys- 
tem of  therapeutics;  and  secondly,  one  which  is  strictly 
scientific,  which  depends  for  its  action  upon  the  known 
causes  of  disease  and  upon  the  action  of  the  agent  on 
that  cause. 

Empirical  Therapeutics.— To  illustrate:  from  the  time 
when  the  Spaniards  invaded  Peru  four  or  five  centuries 
ago,  to  the  present  time,  a  more  or  less  large  percentage 
of  the  human  race  has  taken  quinine  to  cure  malaria. 
That  is  a  matter  of  common  knowledge.  One  does  not 
have  to  be  a  physician  or  a  dentist  to  know  that.  Any 
layman  can  tell  that  quinine  is  a  good  thing  for  malaria, 
that  is,  if  he  is  a  sensible  sort  of  layman  (although  once 


SCHOOLS  OF  THERAPY  121 

in  a  while  one  is  met  who  says,  "I  can't  take  quinine  be- 
cause it  does  something  to  the  blood  or  bone") ;  but  the 
average,  intelligent  person  knows  that  quinine,  or  cin- 
chona, from  which  it  comes,  is  an  agent  that  cures  ma- 
laria. Now,  that  fact  has  been  taken  advantage  of  for 
400  years.  Only  a  few  years  ago  was  it  discovered  that 
quinine  acted  upon  the  direct  cause  of  malaria  and  there- 
fore cured  the  disease.  By  that  is  meant  that  the  specific 
cause  of  malaria,  the  so-called  plasmodium  malariae  or 
specific  causative  germ,  was  discovered.  It  was  further 
found  that  if  a  clump  of  these  bacteria  were  placed  in 
solution,  in  a  glass  tube,  and  poured  into  a  sufficiently 
strong  solution  of  quinine,  they  would  die,  and  there  is 
a  very  simple  explanation  of  the  fact  that  malaria  can 
be  cured  by  quinine. 

So  from  a  system  of  what  we  may  call  empirical  thera- 
peutics, a  scientific,  exact  method  of  treating  disease  is 
evolved.  Unfortunately,  the  causative  agent  of  all  dis- 
eases is  not  yet  known,  and  until  it  is  known  it  cannot 
be  expected  that  a  remedy  will  be  produced  that  will  cure 
every  disease.  The  number  of  diseases  that  can  be 
treated  scientifically  is  all  the  time  increasing.  There  is 
hope  that  some  day  there  will  be  nothing  but  strictly 
scientific  therapeutics;  but  today  it  must  be  said  that 
there  are  scientific  therapeutics,  which  have  been  de- 
scribed, and  also  empirical  therapeutics.  Now,  when 
a  man  has  malaria  and  takes  quinine,  the  physician  knows 
why  he  is  giving  it  to  him.  Thus  the  system  of  empirical 
therapeutics  is  based  on  the  observation  of  skilled  and 
competent  observers  having  extensive  facilities  for  ob- 
servation up  to  the  present  time,  and  on  the  mass  of  ex- 
perience that  has  been  accumulated  in  that  way. 

The  men  who  are  making  studies  on  this  subject  are 
comparing  notes  and  sifting  the  evidence  all  the  time, 
and  there  is  today,  in  almost  any  text-book  of  value  on 
this  subject,  a.  collection  of  the  results  of  these  observa- 
tions, and  that  is  the  basis  of  our  therapeutics  that  is 


L22  PHARMACOLOGY 

called  empirical.  It  may  be  asked  why  a  certain  remedy 
is  given  for  a  certain  disease.  The  answer  is, — one 
which  can  be  made  in  the  case  of  quinine, — that  it  de- 
stroys the  cause  of  the  disease.  If  that  cannot  be  said, 
the  answer  is  that  the  observation  of  skilled  observers 
up  to  the  present  time  goes  to  show  that  that  remedy 
is  indicated  in  that  disease.  That  is  as  far  as  one  can 
go.  That  kind  of  therapeutics,  however,  is  lessening 
all  the  time,  and  the  scientific  kind  is  widening  all  the 
time. 

Various  Therapeutic  Systems 

Special  Therapies.— What  about  these  special  thera- 
pies like  homeopathy,  hydrotherapy,  thermotherapy,  and 
all  those  different  kinds  of  therapy  so  prevalent  today? 
They  are  built  up,  it  would  seem,  on  the  basis  of  a  pre- 
conceived idea.  That  is,  a  man  assumes  that  certain 
things  are  true,  then  goes  to  work  to  build  up  a  theory 
around  them. 

Homeopathy.— The  homeopath  says,  "Like  cures  like." 
That  means  that  a  disease  producing  certain  symptoms 
is  cured  by  an  agent  that  will  produce  those  symptoms. 
For  instance,  a  man  having  scarlet  fever  has  a  rash. 
Now,  "like  cures  like"  means,  if  it  means  anything,  that 
when  one  is  going  to  treat  that  disease  one  must  give 
the  patient  something  that  will  produce  that  same  symp- 
tom ;  and  to  cany  the  illustration  further,  one  knows  that 
belladonna,  given  in  a  reasonable  amount,  will  make  a 
man's  skin  break  out  with  a  rash,  resembling  scarlet 
fever.  Therefore,  according  to  the  principle  of  "like 
cures  like,"  if  a  man  has  scarlet  fever  one  should  give 
him  belladonna,  because  one  gets  the  same  symptoms 
from  belladonna  as  from  scarlet  fever.  Sensible  men 
and  women  will  agree  that  this  seems  a  rather  absurd 
theory. 

On  principles  like  the  foregoing  is  built  up  the  system 
of  homeopathy.    One  does  not  want  to  misrepresent  the 


SCHOOLS  OF  THERAPY  123 

homeopath.  There  are  many  practicing  medicine  as 
homeopaths.  They  have  graduated  from  homeopathic 
schools,  but  it  can  be  stated  absolutely  that  there  is  not 
a  graduate  of  the  last  15  years,  or  10  years,  in  this  coun- 
try who  is  practicing  a  strict  homeopathy  today.  They 
give  drugs,  just  as  any  other  sensible  man  does.  As 
for  homeopathy,  a  certain  amount  of  good  has  resulted 
from  its  introduction.  It  has  taught  medical  men  to  be 
a  little  more  careful  as  to  the  forms  of  medicine  they 
administer.  The  old-time  doctor  was  a  crude  fellow 
who  used  to  carry  his  pills  and  potions  around  in  rather 
a  loose  wTay  and  administer  them  without  much  regard 
to  their  physical  appearance  or  taste.  The  patient  took 
them  or  left  them  as  he  pleased.  The  homeopathic  phy- 
sician came  along  with  a  little  vial  full  of  white  globules 
that  tasted  good.  A  patient  would  rather  take  those,  if 
they  would  do  as  much  good,  than  take  the  vile-smelling 
tincture  that  the  old  doctor  gave.  The  result  was  that 
the  homeopath  got  a  good  deal  of  business  from  the 
class  of  patients  who  got  along  very  well  whether  they 
took  medicine  or  not.  It  is  an  open  secret  in  disease  that 
a  certain  percentage  of  cases  will  get  well  if  one  does  not 
do  anything  to  prevent  it.  In  that  class  of  cases  the 
homeopath  can  get  along  beautifully,  because  the  patient 
likes  to  take  the  medicine.  So  they  built  up  a  large  busi- 
ness. It  has  been  said  by  those  who  are  inclined  to  ridi- 
cule homeopathy  that  the  homeopath  appeals  to  children 
and  old  women  of  both  sexes ! 

For  instance,  in  the  case  of  a  rather  turbulent  ^hikl 
to  whom  it  is  necessary  to  give  some  medicine,  that 
child  would  take  some  sugar  tablets  much  easier  than  a 
tablespoonful  of  sulphate  of  magnesium.  That  kind  of 
case  accounts  to  a  certain  extent  for  the  popularity  of 
the  homeopath  and  also  for  the  fact  that  the  physician 
of  the  regular  school, — as  it  is  called, — the  old-time  phy- 
sician, has  become  more  careful  in  the  form  of  drug  he 
administers.     Elegant  pharmacy  has  been  the  result  of 


124  PHARMACOLOGY 

homeopathy.  Today  the  agents  are  presented  to  the 
patient  in  as  attractive  and  palatable  a  form  as  possible. 

Now  what  has  been  said  about  homeopathy  applies 
in  a  greater  or  less  degree  to  all  of  the  special  classes 
of  medicine.  It  is  as  well  not  to  be  bound  to  any  particu- 
lar school,  but  to  say, — "Here  is  a  human  body  that  I 
have  studied  about,  know  about.  Here  is  an  agent  that 
will  do  certain  things  to  this  body,  I  believe,  because  I 
know  the  cause  of  the  pathological  condition.  Therefore 
I  will  give  it  that  agent."  If  that  cannot  be  done,  say, 
"Men  have  been  investigating  this  subject  for  hundreds 
of  years  and  the  consensus  of  opinion  is  that  this  is  the 
agent  to  use,  and  therefore  I  use  it."  That  is  a  good 
reason,  not  because  of  "like  cures  like"  or  any  other  such 
fetish  as  that. 

Christian  Science. — In  these  days  of  mental  suggestion 
Christian  Science  has  become  quite  a  profession.  Many 
people  think  they  are  cured  of  disease  by  a  process  of 
mental  healing  or  Christian  Science.  Many  of  them  are 
excellent  people,  people  of  high  character,  quick  sympa- 
thies, and  remarkable  intelligence  in  a  good  many  ways, 
and  there  is  something  in  the  theory.  Of  course,  anyone 
who  is  observant  at  all  knows  that  the  mental  condition 
has  a  good  deal  to  do  with  the  physical  condition.  One 
knows  that  if  he  is  happy  in  his  mind  and  if  he  has 
made  a  thousand  dollars  in  a  stock  speculation,  he  enjoys 
a  good  dinner,  and  it  digests  better  than  if  he  has  lost 
a  thousand.  The  mental  condition  is  affected  and  the 
mental  condition  has  to  do  with  the  well-being  of  the 
body.  Now,  if  a  person  has  a  fancied  ill,  say,  for  in- 
stance, he  thinks  he  has  indigestion,  or  he  thinks'  that 
he  has  oncoming  locomotor  ataxia,  or  that  some  other 
disease  is  hovering  over  him,  his  mental  condition  is 
a  desperate  one  and  one  which  reacts  on  his  physical 
condition.  He  sees  the  symptoms  of  the  disease  which 
he  thinks  he  has.  Exactly  similar  is  the  case  of  the 
man  who  reads  a  patent  medicine  advertisement  which 


SCHOOLS  OF  THERAPY  125 

says — "If  you  get  plant  juice  and  drink  a  full  glass  a 
day  you  will  get  rid  of  that  backache,  that  headache, 
etc."  After  he  has  read  this  particular  advertisement 
over  three  or  four  times,  even  if  he  felt  in  perfect  health 
when  he  began,  by  the  time  he  gets  through  with  it  lie 
will  be  a  pretty  sick  man. 

That  illustrates  just  what  may  happen  by  mental  sug- 
gestion. And  if  a  person  can  get  out  of  his  mind  the 
idea  that  he  is  sick  (if  there  is  really  no  definite  patho- 
logical condition  present)  a  great  deal  has  been  done. 
Even  if  he  is  sick,  to  keep  him  in  a  pleasant,  happy  frame 
of  mind  will  do  more  for  him  than  despondency.  So 
Christian  Science  has  a  field  there,  a  field  in  improving 
the  mental  condition.  If  people  who  believe  in  mental 
suggestion  would  confine  themselves  to  conditions  that 
they  can  safely  treat,  they  would  do  a  lot  of  good,  but 
if  they  attempt  to  treat  broken  legs  or  definite  pathologi- 
cal conditions  that  they  do  not  know  anything  about, 
they  are  liable  to  do  harm. 

Osteopathy.— A  great  many  people  say  they  get  re- 
sults from  osteopathy.  No  doubt  tliey  do.  Osteopathy 
is  simply  a  scientific  massage,  and  everyone  knows  what 
massage  will  do.  Massage  is  a  sort  of  passive  exercise, 
— a  lazy  man's  way  of  taking  exercise.  If  properly  ap- 
plied it  is  of  great  value.  Now,  if  the  osteopath  will 
admit  that  his  manipulation  of  tissue  is  simply  a  re- 
fined and  skillful  massage,  there  is  no  ground  for  quar- 
rel with  him;  but,  if  he  claims,  as  some  do,  that  the  man 
who  has  a  pain  in  the  back  of  his  neck,  has  dislocation 
of  the  cervical  vertebra,  and  that  he  can,  by  manipula- 
tion, snap  back  one  of  those  vertebrae  into  place,  one 
would  say  that  perhaps  he  is  claiming  more  than  he  is 
justified  in  claiming.  There  was  once  an  osteopath  who 
had  great  success  in  relieving  pain  in  the  back  of  the  neck. 
In  every  case  he  told  his  patients  that  the  cervical  verte- 
brae were  displaced,  that  he  could  get  them  back  by 
manipulation  and  they  would  be  relieved.     He  had  a 


126  PHARMACOLOGY 

trick  of  cracking  one  of  his  thumbs  every  little  while  and 
saying — "There,  hear  that  bone  slip  back, — there  it  is!" 
And  the  cure  resulted.  Now  these  statements  are  not 
intended  to  ridicule  osteopathy,  because  the  man  who 
practices  osteopathy  on  proper  lines  does  a  great  deal 
of  good.  There  is  no  doubt  but  that  proper  manipula- 
tion of  the  pathological  tissue  is  a  great  factor  in  the 
treatment  of  disease,  and  the  medical  student,  and  the 
dental  student,  should  have  instruction  in  that  sort  of 
thing. 

Therapeutic  Fallacies.— The  fallacy  of  the  whole  thing, 
however,  is  the  attempt  to  build  up  a  system  of  therapeu- 
tics on  one  particular  tenet,  one  particular  system,  a  pre- 
conceived idea  that  a  certain  thing  must  happen,  that 
one  can  cure  all  disease  by  water — that  is,  hydrotherapy; 
that  one  can  cure  all  diseases  by  heat — that  is,  thermo- 
therapy ;  that  one  can  cure  all  diseases  by  massage — that 
is,  osteopathy. 

Nihilism  in  Therapeutics.— The  tendency  to  therapeu- 
tic nihilism  is  pretty  prevalent  in  Massachusetts,  and  it 
is  generally  though  not  always  true  that  the  more 
strongly  a  person  becomes  a  therapeutic  nihilist  the 
poorer  physician  he  is.  This  does  not  mean  that  one  must 
dose  every  patient  he  meets,  but  it  does  mean  that  if  the 
physician  uses  the  agents  at  his  control  in  an  intelligent 
way  he  will  do  his  patients  more  good,  and  incidentally 
himself  more  good. 

PRESCRIPTION  AND  ADMINISTRATION  OF  DRUGS 

Prescriptions. — In  the  administration  of  remedies  it  is 
necessary  to  write  prescriptions.  A  formal  prescription 
is  a  written  direction  from  the  attendant, — physician 
or  dentist, — to  the  pharmacist,  to  dispense  to  the  patient 
certain  remedial  agents,  and  should  contain  on  its  label 
certain  directions  for  the  patient  as  to  how  to  take  that 
remedy.    Now,  many  times  an  oral  prescription  is  given : 


PRESCRIPTION  OF  DRUGS  127 

to  tell  a  man  to  take  some  salt  water  and  rinse  out  his 
mouth  three  times  a  day  is  an  oral  prescription.  It  is 
just  as  much  the  function  of  the  dentist  to  prescribe  as 
of  the  physician.  When  his  degree  is  obtained,  the  dentist 
has  the  same  right  to  prescribe  as  the  M.  D.  has,  and  he 
is  held  under  the  same  restrictions  in  prescribing. 

Methods  of  Measuring.— In  writing  prescriptions  there 
are  two  methods  of  measuring, — the  old  or  apothecaries' 
system  of  weights  and  measures,  and  the  metric  or  deci- 
mal system  of  weights  and  measures,  about  which  more 
will  be  said  later. 

Materia  Medica  and  Therapeutics.— Materia  medica 
means,  roughly  speaking,  the  materials  used  in  the  treat- 
ment of  disease;  therapeutics,  any  means  used  for  the 
treatment  of  a  pathological  condition.  Anything  done 
for  the  care  of  patients  is  therapeutics ;  thus,  to  tell  them 
to  raise  the  window  shades,  to  get  in  fresh  air,  is  part  of 
therapeutics ;  a  sponge  bath  is  therapeutics.  Technically, 
however,  by  therapeutics  is  meant  the  administration  of 
drugs. 

Administration  of  Drugs 

Pharmacology;  Pharmacodynamics;  Pharmacy. — 
Pharmacology  is  a  term  used  to  embrace  both  materia 
medica  and  therapeutics,  and  means,  literally,  a  discus- 
sion of  drugs.  Pharmacodynamics  signifies  the  action 
of  drugs  on  the  human  system.  Pharmacy  is  the  art  of 
preparing  and  dispensing  remedial  agents,  and  is  the 
province  of  the  pharmacist. 

Means  of  Introducing  Drugs.— The  administration  of 
drugs  and  the  ways  in  which  they  can  be  taken  into  the 
body  are  next  to  be  considered,  and  in  this  respect  the 
body  can  be  treated  as  a  whole.  The  human  body  is 
covered  with  skin  and  has  cavities  lined  with  mucous 
membrane.  To  get  a  drug  into  the  system,  then,  there 
are  two  modes  of  entrance — either  through  the  skin  or 
through  the  mucous  membrane.     It  is  evident  that  one 


L28  PHARMACOLOGY 

cannot  get  into  the  circulation  otherwise.  Of  these  two 
avenues,  the  skin  will  be  lirst  considered. 

The  Skin. — If  an  agent  or  a  drug  is  placed  on  the  skin 
there  will  be  some  result  with  some  drugs,  some  ab- 
sorption; and  if  it  is  rubbed  in,  there  will  be  still  more. 
By  taking  a  needle  and  piercing  the  skin,  and  then  in- 
jecting a  fluid  into  the  subcutaneous  areolar  tissue  the 
maximum  result  will  be  obtained.  The  epidermis  may 
be  removed  by  blistering,  and  the  agent  put  on  the  raw 
surface  to  be  absorbed  that  way,  but  that  is  not  usually 
done. 

Mucous  Membrane. — In  considering  the  mucous  mem- 
brane as  an  avenue  for  drugs  there  is,  first,  the  digestive 
tract,  beginning  with  the  lips  and  ending  with  the  anus. 
Here  there  is  a  surface  that  can  be  brought  in  contact 
with  drugs  to  get  results  from  them.  That  is,  of  course, 
by  far  the  most  common  way.  Most  drugs  are  thus  ad- 
ministered, taken  into  the  mouth,  carried  into  the  stom- 
ach and  absorbed.  That  is  one  of  the  routes  by  the 
mucous  membrane.  A  drug  can  be  injected  into  one  of 
the  cavities  of  the  body — into  the  urethra,  the  vagina,  or 
the  rectum — and  it  will  be  absorbed.  It  can  be  dropped 
into  the  conjunctiva  of  the  eye,  or  it  can  be  inhaled  and  be 
thus  absorbed  through  the  respiratory  mucous  membrane. 

Time  for  Administering  Drugs.— The  time  at  which  to 
administer  a  drug  is  important,  particularly  with  rela- 
tion to  meals.  A  drug  taken  before  meals  is  more 
promptly  active  than  if  taken  after  meals.  If  it  is  taken 
on  an  empty  stomach  it  strikes  a  fairly  clear  mucous 
membrane  and  is  absorbed  directly. 

Dangers  of  Toleration.— If  a  drug  is  given  for  a  long 
period  of  time  a  toleration  will  result.  By  toleration  is 
meant  the  effect  of  a  drug  upon  the  system  by  which  the 
normal  or  initial  effect  is  lost.  To  illustrate  this  point, 
a  great  many  men  have  learned  to  smoke.  The  first  time 
they  did  not  enjoy  it.  Occasionally  one  meets  a  person 
who  says  he  enjoyed  his  first  smoke,  but  most  people  do 


PRESCRIPTION  OF  DRUGS  129 

not.  It  is  remembered  with  horror.  However,  after  try- 
ing a  few  times  with  praiseworthy  perseverance  they 
succeed  in  "learning  to  smoke,"  as  it  is  called.  That  is, 
a  toleration  for  the  drug  is  set  up.  What  has  happened 
is  that  the  system  has  become  accustomed  to  the  action 
of  that  drug.  One  can  obtain  toleration  of  almost  any 
drug  by  a  continuance  of  its  use.  If  morphin  is  taken 
to  control  pain,  an  eighth  of  a  grain  will  give  relief  at 
first,  but  if  this  is  kept  up  for  six  months,  it  would  prob- 
ably take  a  grain  or  two  then  to  get  the  same  result, 
and  finally  there  would  come  a  point  where  the  most 
excessive  doses  would  give  no  results.  That  is  what  is 
meant  by  toleration. 

The  sex  of  a  patient  has  something  to  do  with  the 
effect  of  a  drug.  Women  react  to  drugs  more  promptly 
and  more  powerfully  than  men,  so  that  the  dose  has  to 
be  a  little  smaller. 

Determination  of  Dosage  by  Age.— Many  rales  have 
been  devised  for  the  determination  of  the  proper  dose 
for  different  ages.  The  simplest  one  is  this :  The  adult 
age  can  be  considered  as  twenty.  Anyone  under  twenty 
will  take  that  fraction  of  the  total  dose  that  his  age  is 
of  twenty.  If  the  patient  is  five,  he  will  take  one-fourth 
of  the  dose;  ten,  he  will  take  ten-twentieths;  fifteen,  fif- 
teen-twentieths or  three-fourths  of  the  dose.  That  is  ac- 
curate enough  for  practical  purposes.  Young's  rule  is  to 
divide  the  age  by  the  age  plus  twelve ;  but  the  more  com- 
plex the  rale,  the  more  likely  one  is  to  get  mixed. 

Determination  of  Dosage  by  Weight.— Another  way  to 
determine  the  dose  is  by  weight.  The  average  person  is 
supposed  to  weigh  150  pounds.  A  man  weighing  200 
pounds  should  thus  take  two  hundred-one  hundred  and 
fiftieths  of  the  dose  (or  one  and  one-third  times  the  dose) ; 
a  man  weighing  50  pounds,  one-third  of  the  dose;  300 
pounds,  twice  the  dose.  That  is  the  most  accurate  of  all 
the  rules.  It  has  no  reference  to  age,  but  to  the  avoirdu- 
pois to  be  affected. 


130  PHARMACOLOGY 


THE  METRIC  SYSTEM 


Weights  and  Measures.— The  subject  of  Weights  and 
Measures  now  claims  attention.  A  dentist  is  supposed 
to  be  a  man  who  writes  prescriptions  and  has  a  legal 
right  to  do  so,  so  that  the  matter  of  prescription-writing 
and  the  matter  of  weights  and  measures  become  of  con- 
siderable importance  to  him.  Most  dentists  absorbed  in 
their  schooldays  a  knowledge  of  the  apothecaries'  table 
of  weights  and  measures  as  a  part  of  their  mental  pabu- 
lum. The  matter  of  the  metric  system,  however,  seems 
to  be  a  stumbling  block  to  many  students,  and  yet  this 
system  is  ultimately  much  easier  to  use  and  by  far  the 
most  scientific  and  accurate. 

Metric  System.— The  metric  system  follows  the  decimal 
system  of  United  States  money,  the  basis  of  the  system 
being  the  meter.  The  attempt  was  made  to  get  an  accu- 
rate and  unchangeable  standard  of  weights  and  meas- 
ures, so  the  authors  of  the  system  took  a  quadrant  of 
the  earth,  the  distance  from  the  equator  to  the  pole,  and 
called  one  ten-millionth  of  that  distance,  the  meter,  or 
39.37  inches  (a  little  over  three  feet).  It  can  be  thought 
of  as  a  large  yard.  That  meter  is  the  basis  of  the 
whole  system.  From  that  one  unit  may  be  calculated 
all  the  units  of  measure,  of  weight,  and  of  capacity.  The 
divisions  of  that  meter  are  indicated  by  using  Latin 
prefixes.  Thus  a  decimeter  is  a  tenth  of  a  meter,  a  cen- 
timeter a  hundredth,  and  a  millimeter  a  thousandth 
of  a  meter.  In  the  ascending  scale  Greek  prefixes 
are  used :  thus  a  dekameter  is  ten  meters,  a  hectometer 
is  one  hundred  meters,  a  kilometer  is  one  thousand 
meters.  A  hollow  cube  measuring  one  centimeter  each 
way  is  called  a  cubic  centimeter.  Now  the  amount  of  dis- 
tilled water  that  can  be  put  into  such  a  cube  is  a  cubic 
centimeter ;  and  in  measuring  liquids  in  the  United  States 
that  amount  of  liquid  is  spoken  of  either  as  a  gram  by 


PRESCRIPTION  WRITING  131 

weight  or  as  a  cubic  centimeter,  and  is-;  expressed  by  the 
letters  c.c.  Usually  in  prescribing  in  the  United  States 
the  term  c.c.  is  used  rather  than  the  gram,  that  is,  meas- 
ure rather  than  weight,  although  in  its  essence  the  sys- 
tem contemplates  weighing  everything.  The  term  mil 
is  also  used  to  express  the  same  unit.  From  that  unit 
of  weight,  the  gram,  are  derived  the  fractions  of  a  gram 
and  the  multiples  of  a  gram  in  the  same  way  as  with  the 
meter.  Thus  one  says,  decigram  for  a  tenth  of  a  gram, 
centigram  for  a  hundredth,  and  milligram  for  a  thou- 
sandth of  a  gram;  for  ten  grams  the  term  dekagram  is 
used;  for  a  hundred  grams,  hectogram;  and  for  a  thou- 
sand grams,  kilogram.  Now,  having  learned  that  the 
unit  of  weight,  the  gram,  is  the  amount  which  a  cubic 
centimeter  of  water  of  4°  C.  would  weigh,  one  has  a 
basis  of  weight  and  one  can  express  any  denomination 
required  from  that. 


PRESCRIPTION  WRITING 

Prescription  Blanks.— A  prescription,  as  has  been  said, 
is  a  written  direction,  from  the  dentist  to  his  patient,  to 
be  taken  to  the  druggist  or  pharmacist  to  compound  or 
dispense  certain  agents  which  the  patient  in  turn  is  to 
take.  An  up-to-date  dentist  will  take  care  to  have  proper 
blanks.  A  prescription  written  on  brown  wrapping 
paper,  even  in  accurate  terms,  would  not  commend  itself 
to  the  average  discriminating  patient.  So  that  a  proper 
blank,  with  certain  data  upon  it,  would  of  itself  be  of 
some  value  in  establishing  the  standing  of  a  dentist  in  the 
community.  This  blank  at  the  top  should  be  in  a  certain 
way  the  card  of  the  dentist.  Supposing  that  his  name 
is  John  Jones,  D.M.D.,  and  that  he  lives  at  125  Beacon 
Street,  Boston,  and  that  his  telephone  number  is  101 
Back  Bay,  and  that  his  hours  are  9-12  AM.  and  2-4  P.M., 
that  will  add  to  the  knowledge  to  be  given  to  the  patient. 


L32  PHARMACOLOGY 

There  is,  in  fact,  a  professional  card,  and  when  a  pre- 
scription is  written  if  that  is  handed  to  the  patient  he 
receives  valuable  information,  and  he  will  be  impressed 
with  the  fact  that  his  dentist  is  a  man  who  is  careful  of 
detail.  The  word  "For"  can  be  printed  with  a  blank  left 
for  the  name,  Thomas  Smith,  with  space  for  the  address, 
if  desired.  At  one  corner  can  be  added  another  blank 
for  the  date.  Thus  the  form  denotes  something  for  Mr. 
Thomas  Smith  and  that  he  is  to  take  as  a  document  to 
the  pharmacist. 

A  prescription  which  might  be  used  by  the  dental  pro- 
fession would  go  somewhat  as  follows: 

Model  for  Writing  Prescriptions.— "  It  "—that  stands 
for  the  Latin  word  Recipe,  which  means  "take."  The 
derivation  is  from  the  sign  of  the  zodiac  that  represented 
Jupiter,  the  king  of  the  gods,  and  in  ancient  times  when 
a  prescription  was  written  or  when  some  direction  was 
given,  the  deity  was  invoked  to  aid  in  the  action  of  the 
remedy.  Written  in  that  way  it  means  "Take,"  and 
is  a  direction  to  the  druggist.  In  this  particular  pre- 
scription, perhaps,  Acidi  Benzoici  is  to  be  taken.  That 
is  the  proper  form  which  is  used  to  represent  one  in- 
gredient of  the  prescription  and  is  to  be  translated  "of 
Benzoic  Acid."  Then  follows  the  quantity,  so  many 
ounces  or  grams  of  this  agent.  It  will  be  noticed  that 
it  is  expressed  in  Latin.  There  are  many  good  reasons 
for  this.  In  the  first  place,  Latin  is  a  dead  language  and 
not  subject  to  change.  The  English  language  is  changing 
every  year.  Latin,  however,  is  a  fixed  standard  and 
means  the  same  thing  everywhere.  It  is  a  universal 
language  among  educated  people  and  can  be  translated 
in  Petrograd,  Vienna,  Paris,  London  or  New  York.  Also, 
as  a  rule,  it  cannot  be  read  by  the  patient.  It  ex- 
presses a  thing  in  terms  with  which  he  is  not  acquainted. 
This  is  often  most  desirable.  There  are  many  good  rea- 
sons why  one  ought  not  to  let  the  patient  know  exactly 
what  he  is  getting.    If  salt  and  water  were  ordered  in- 


PRESCRIPTION  WRITING  133 

stead  of  sodium  chlorid,  the  patient  might  think  that  the 
doctor  did  not  know  any  more  than  he  did  about  such 
things.  That,  then,  is  a  reason  for  using  the  Latin  lan- 
guage. However,  a  prescription  written  in  good  English 
is  preferable  to  one  in  poor  Latin.  The  tendency  to  em- 
ploy English  is  increasing  every  day.  Those  not  familiar 
enough  with  Latin  terms  to  write  a  prescription  in  Latin 
had  better  write  in  English. 

Take  Benzoic  Acid  5i=4  00 

Now,  one  can  translate  that  into  the  terms  of  the  met- 
ric system.  As  has  been  said,  the  unit  of  weight  in  the 
metric  system  is  the  gram,  that  is,  about  15.5  grains. 
Now  as  a  dram  is  (50  grains,  a  dram  would  be  about  four 
of  those  grams.  In  using  the  metric  system  it  is  custom- 
ary to  have  the  prescription  blank  divided  by  perpendic- 
ular lines,  one  side  of  the  line  representing  grams,  the 
other  side  fractions.  The  way  to  transpose  a  dram  into 
grams  is  to  multiply  it  by  four. 

Now  to  that  can  be  added: 

Tincture  of  Krameria  5iv=16  00 

That  is  simply  a  vegetable  bitter  with  some  astringent 
qualities,  often  used  as  a  mouth  wash. 

Four  drams  of  that  equals  a  half  ounce.  This  is  a  liquid, 
ex] tressed  in  terms  of  fluid  measure,  16  grams  in  weight 
or  16  c.c.  by  measure.  The  gram  is  the  weight  of  a  cubic 
centimeter  of  a  liquid  at  a  certain  temperature,  so  that  4 
drams  will  equal  four  times  as  many  grams  or  cubic 
centimeters,  which  in  America  is  the  term  generally  in 
use  in  speaking  of  liquids.  In  the  Continental  system  it 
is  generally  weighed;  in  America  it  is  generally  meas- 
ured. Sixteen  is  either  grams  or  cubic  centimeters,  as 
one  pleases. 

Oil  of  Peppermint  Gtt.  xx=1.25 

Gtt.  is  an  abbreviation  for  Gutta,  the  Latin  for  drop. 
Here  there  are  20  drops.     Now,  as  a  gram  is  equal  to 


134  PHARMACOLOGY 

about  15  grains,  or  15  drops,  by  a  very  simple  arithmeti- 
cal process  one  can  conclude  that  20  drops  will  equal 
about  1.25  c.c,  which  will  be  expressed  in  this  way. 
Usually  this  is  carried  out  to  the  milligram  place.  That 
means  that  oil  of  peppermint,  20  drops,  or  1.25  grams  is 
to  be  taken. 

To  that  let  there  be  added: 

Alcohol       qs.  ad       iv 

enough  to  actually  make  up  four  ounces.  Qs.  means 
quantum  sufficit;  ad  means  up  to. 

4  x  30=120  grams,  or  120  c.c. 

Here,  then,  are  the  ingredients.  To  recapitulate:  oil  of 
peppermint  20  drops,  or  1.25  c.c.  (Remembering  that  a 
gram  equals  15  grains  in  liquid  measure,  a  cubic  centi- 
meter equals  15  minims  or  15  drops,  so  that  20  drops  will 
be  a  gram  and  a  quarter.)  Alcohol  is  then  added  in 
sufficient  quantity  to  make  four  ounces.  This  covers  the 
ingredients. 

Next  is  written  the  sign  M,  which  means  to  mix  to- 
gether ;  followed  by  et  Sig.,  meaning  mix  and  mark.  How 
is  the  pharmacist  going  to  mark  this?  "One-half  tea- 
spoonful  (and  the  word  teaspoon  is  allowable  in  such 
prescriptions)  in  a  glass  of  water  for  mouth  wash."  Of 
course  the  term  teaspoon  is  inaccurate.  It  is  not  al- 
lowable if  a  powerful  agent  is  used.  In  a  not  very  pow- 
erful mouth  wash  one  is  perfectly  justified  in  using  tea- 
spoon for  a  measure.  One-half  dram,  or  two  cubic  centi- 
meters, might  be  substituted  for  teaspoon,  and  would  be 
more  accurate. 

In  regard  to  signing  a  prescription,  the  careful  dentist 
will  have  a  blank  and  write  his  name.  He  will  not  have 
his  signature  printed.  If  he  did,  anyone  could  take  the 
blank  and  have  it  filled.  So,  if  his  name  is  John  Jones, 
he  will  write  it;  and  if  he  has  D.M.D.  at  the  top,  it  will 
not  be  necessary  at  the  bottom.    That,  however,  is  really 


PRESCRIPTION  WRITING  135 

a  matter  of  individual  taste.  Yet  one  reason  why  the 
title  should  be  put  there  is  that  it  makes  the  signature 
official  and  shows  the  patient  that  one  is  signing  as 
a  registered  dentist,  which  on  the  whole  it  is  as  well  to 
indicate.  Then  follows  the  complete  prescription  in  its 
proper  form: 

JOHN  JONES,  D.M.D. 
125  Beacon  St.,  Boston.  Tel.  B.B.  101 

For         Thomas  Smith. 

B 

Acidi  Benzoici  5i  =  4  00 

Tinct.  Krameriae  5iv=16  00 

Olei  Pepperminti  Gtt.  xx=1.25 

Alcohol  qs.  ad  oiv 

M  et  Sig. :    One-half  teaspoonful  in  glass  of 
water  for  mouth  wash. 

John  Jones,  D.M.D. 

That  is  a  form  wiiich  will  surely  pass  muster.  If  one 
can  write  a  prescription  according  to  that  form,  he  will 
be  able  to  satisfy  the  patient  that  he  is  up-to-date  as 
far  as  prescription  writing  is  concerned.  There  are 
plenty  of  text-books  to  which  reference  can  be  made  in 
the  matter  of  prescription  writing,  and  it  is  essential  that 
any  up-to-date  dentist  should  be  able  to  write  a  passage 
prescription.  It  is,  perhaps,  a  matter  of  advertising,  but 
it  is  also  a  matter  of  showing  to  the  public  and  to  one's 
patients  that  one  is  up  to  modern  requirements  in  these 
matters.  Of  course,  the  dentist  does  not  have  occasion 
to  write  prescriptions  as  often  as  does  the  medical  man, 
because  he  does  not  use  drugs  so  much. 

Summary.— An  attempt  has  been  made  here  to  show 
in  a  very  brief  way  the  general  principles  of  prescrip- 
tion writing  and  the  method  of  transposing  from  the  me- 


136  PHARMACOLOGY 

trie  system  to  apothecaries'  weight,  and  vice  versa.  To 
recapitulate :  there  are  certain  things  to  be  borne  in  mind, 
and  first  is  to  get  the  idea  of  what  a  gram  is.  That  is 
the  unit.  Then  comes  the  term  cubic  centimeter,  and 
that  is  explained  by  recalling  that  a  centimeter  is  a  hun- 
dredth part  of  a  meter;  or,  in  other  words,  it  is  something 
like  one-third  of  an  inch.  A  meter  is  the  ten-millionth 
part  of  the  distance  from  the  equator  to  the  pole. 

The  Standard  Meter.— The  unit  of  the  whole  system  is 
the  meter.  The  distance  has  been  pretty  accurately  de- 
termined, and  most  governments  have  a  platinum  rod 
that  is  exactly,  as  far  as  government  authority  can  make 
it,  a  meter;  and  it  is  made  of  metal  that  does  not  shrink 
or  expand  very  much  with  changes  of  temperature. 

Apothecaries'  Weight. — The  standard  of  apothecaries' 
weight  is  very  variable.  It  is  based  on  the  grain,  and 
when  man  first  began  to  measure  things,  the  unit  was  a 
grain  of  wheat  well  dried,  which  of  course  is  very  vari- 
able. The  one-meter  metal  rod  referred  to  is  kept  in 
the  Bureau  of  Weights  and  Measures  as  a  standard.  So 
the  great  advantage  of  the  metric  system  is  in  having 
a  stable  unit.  That  old  table,  60  grains  make  a  dram ;  8 
drams  make  an  ounce;  and  12  ounces  make  a  pound  will 
probably  be  remembered.  There  is  no  relation  between 
them.  It  is  a  matter  of  clear  memory.  On  the  other 
hand,  10  meters  is  a  dekameter,  100  meters  a  hecto- 
meter, and  1000  meters  a  kilometer.  There  is  something 
that  is  easily  remembered  and  is  so  comparable  to  our 
American  system  of  money  that  it  makes  it  very  much 
easier  to  remember;  and,  as  has  been  said  before,  the 
metric  system  would  probably  be  learned  for  the  first 
time  in  half  the  time  that  one  would  learn  the  other. 

One  or  two  other  things  can  be  said  in  regard  to  the 
metric  system.  In  measures  of  capacity  the  unit  of 
liquids  of  large  amounts  is  the  liter,  which  is  a  kilogf  am 
by  weight.  A  kilogram  is  1000  grams  and  a  liter  weighs 
1000  grams.     One  thousand  grams  of  water  at  4°  C.  is 


ANALGESICS  137 

a  litei\  The  term  liter  is  not  often  used  in  prescribing, 
so  that  it  is  not  specially  important.  Some  of  the  essen- 
tial things  about  the  metric  system  of  weights  and  meas- 
urements have  now  been  reviewed  and  something  has 
been  learned  in  a  general  way  about  prescriptions :  the 
ability  to  write  them  depends  now  upon  careful  reference 
to  the  text-book  on  the  subject. 


ANALGESICS 

A  word  can  be  said  here  about  specific  drugs,  some  of 
the  drugs  that  are  particularly  interesting  to  the  dentist. 

Opium.— One  of  these  drugs  is  opium,  because  opium 
is  a  drug  that  dentists  have  occasion  to  use.  It  is  the 
king  of  analgesics  and  one  of  the  most  powerful  of  these 
agents  that  there  is.  It  is  known  that  there  exists  in  this 
country  a  certain  law  under  the  provisions  of  which  one 
must  prescribe  certain  drugs,  and  among  them  opium. 
Certain  conditions  are  defined  under  which  the  drug  must 
be  prescribed.  A  fee  of  one  dollar  must  be  paid  and  reg- 
istration made.  There  are  also  certain  restrictions  in 
regard  to  the  way  in  which  the  drug  can  be  bought. 
Dentists  are  subject  to  that  law,  but  they  have  just  as 
much  right  to  prescribe  opium  as  medical  men  have. 

Opium  is  a  vegetable  known  technically  as  Papaver 
somniferum,  the  sleep-producing  poppy.  The  poppy  tribe 
has  various  branches,  but  this  particular  kind  is  the 
sleep-producing  poppy,  so  called  because  it  makes  a  man 
sleep  if  he  takes  very  much  of  it.  Opium,  as  it  is  known 
in  commerce,  is  the  dried  juice  of  the  poppy  plant.  The 
juice  exudes  and  collects  in  a  sort  of  globule  or  ball, 
and  is  thus  obtained  in  the  form  of  crude  opium.  This 
is  usually  of  a  dark  brown  color.  Opium  yields  its  active 
principles  to  water  fairly  well,  in  the  form  of  a  tincture. 
It  can  be  prescribed  in  its  crude  form.  The  tincture  of 
opium,  known  as  laudanum,  is  ten  per  cent  in  strength. 


138  PHARMACOLOGY 

So  that  when  a  certain  amount  of  laudanum  is  proscribed 
one  is  prescribing  a  certain  percentage  of  opium.  The 
most  important  alkaloid  of  opium  is  morphin. 

Physiological  Action  of  Opium.  —  The  effect  of  opium 
upon  the  digestive  tract  is  to  check  secretion  and  stop 
action.  If  opium  is  swallowed  the  jiiices  of  the  stomach 
are  dried  up  and  the  peristaltic  action  of  the  digestive 
tract  is  checked.  The  result  is  indigestion  and  constipa- 
tion. The  action  of  the  drug  is  to  check  all  the  secretions 
of  the  body  excepting  those  of  the  perspiratory  glands. 

Pain.  — Opium  relieves  pain,  and  that  is  the  main  rea- 
son for  its  use.  Everyone  knows  what  pain  is  and  every- 
one knows  when  he  has  a  pain.  In  order  to  define  pain 
one  must  consider  what  causes  pain  and  thus  arrive  at 
the  definition.  Pain  is  caused  by  injuring  a  sensory 
nerve.  Pain  itself  is  the  knowledge  of  the  injury  of 
the  sensory  nerve.  One  must  ask,  then,  what  does  opium 
do  and  how  does  it  relieve  pain?  It  controls  pain  by 
destroying  the  conductivity  of  the  nerve  which  conveys 
the  sensation  of  pain  to  the  receptive  centers  of  the 
brain.  The  higher  nerve  centers  are  made  up  of  certain 
areas,  among  which  are  the  receptive  centers.  If  when 
walking  along  the  street  one  sees  an  automobile  coming, 
he  gets  an  idea  of  danger  from  his  eyes;  this  is  con- 
veyed to  the  receptive  centers  which  comprise  his  area 
of  knowledge.  This  information  tells  one  what  to  do. 
This  is  a  direct  physiological  problem.  The  receptive 
center  is  the  center  that  receives  impressions  and  that 
records  the  impression  of  pain.  Now  opium  inhibits  the 
response  by  destroying  the  conductivity  of  those  nerves 
which  should  convey  the  knowledge  of  the  injury  of  a  sen- 
sory nerve  to  the  receptive  center.  No  message  has 
been  carried  to  the  brain  and  therefore  no  pain  is  felt. 
That  is  the  reason  wrhy  dentists  are  justified  in  pre- 
scribing opium,  because  their  patients  are  suffering  from 
pain  about  the  jaw  and  other  places,  and  it  is  justifiable 
to  prescribe  the  drug  to  relieve  this  pain. 


ANALGESICS  139 

Objections  to  Use.— The  main  objections  to  the  use  of 
opium  are  that  it  destroys  to  a  certain  extent  the  digestive 
powers ;  the  patient 's  mouth  becomes  furred ;  he  is  con- 
stipated and  has  no  appetite.  Another  objection  is  the 
danger  of  habit-forming,  therefore  it  should  not  be  pre- 
scribed for  continued  use.  A  single  dose  only  should  be 
prescribed  and  the  patient  always  cautioned  as  to  the 
danger  of  repeating  the  dose  without  consulting  his  ad- 
visor. The  prescription  should  contain  the  abbreviation 
"N.R."  (non  repetatur).  The  form  under  which  opium 
will  be  prescribed  will  be,  as  morphin,  furnished  as  a 
sulphate,  a  white  powder  like  the  alkaloid.  It  is  soluble, 
and  for  the  average  adult  the  dose  is  about  a  quarter  of 
a  grain.  Now  a  grain  is,  roughly  speaking,  65  milligrams, 
so  that  a  quarter  of  a  grain  would  be  about  15  milligrams. 
To  the  average  adult  it  may  be  administered  either  sub- 
cutaneously  or  by  the  mouth ;  this  would  probably  be  the 
main  way  in  which  this  drug  would  be  used  in  practice. 

Coal-tar  Series  of  Drugs 

Analgesics  in  Neuralgia.— There  is  also  the  coal-tar 
series  of  drugs,  which  include  acetphenetidin  and  the 
salicylic  acid  series,  including  acetanilid  and  acetyl  sali- 
cylic acid, — analgesics  of  no  mean  value.  The  distinction 
between  the  action  of  the  coal-tar  series  and  opium  is 
that  the  coal-tar  series  are  applicable  only  to  a  certain 
kind  of  pain.  Ordinarily  a  man  will  get  but  little  relief 
for  pain  inflammatory  in  its  nature.  In  a  case  of  a  sup- 
purating root  little  relief  can  be  obtained  by  administer- 
ing these  coal-tar  drugs,  but  if  the  pain  is  simply  neu- 
ralgic a  certain  amount  of  relief  from  pain  will  be  ob- 
tained. 

Attention  should  be  called  here  to  acetanilid,  acetyl  sali- 
cylic acid  and  acetphenetidin.  These  three  drugs  are 
all  agents  of  value  in  the  treatment  of  pain  which  is  of  a 
neuralgic  character  and  not  due  to  inflammation.     Any 


140  PHARMACOLOGY 

one  of  these  drugs  can  be  taken  in  dosage  of  about  one- 
half  a  gram  for  the  average  adult  dose. 

Acetanilid. — Acetanilid  exists  as  a  white  powder  not 
easily  soluble  and  can  be  given  in  tablet  or  powder  form, 
in  dosage  of  half  a  gram  (7.5  grains),  every  three 
hours,  for  neuralgic  pain.  Tt  is  more  or  less  depressant 
to  the  circulation,  and  those  who  take  a  great  deal  are  apt 
to  show  bad  results.  It  is  an  ingredient  of  most  of  the 
popular  headache  powders,  and  patients  are  seen  who 
suffer  from  periodical  headaches,  with  a  livid  color  of  the 
skin  which  suggests  a  breaking  down  of  the  blood,  and 
that  is  just  what  does  occur  from  continued  use  of  this 
drug.    It  is  a  dangerous  drug  for  self-administration. 

Phenacetin. — Phenacetin,  or  acetphenetidin,  is  also  a 
white  crystalline  powder  which  has  been  brought  to  the 
attention  of  medical  men  and  dental  men  as  an  improve- 
ment on  acetanilid,  on  the  ground  that  it  is  less  depres- 
sant to  the  vital  functions.  There  is  perhaps  some  jus- 
tice in  that  claim,  although  there  is  not  nearly  the  dif- 
ference which  the  literature  on  the  subject  would  lead  one 
to  suppose.  It  is  better  to  use  acetphenetidin  than  ace- 
tanilid. 

Aspirin. — Aspirin  exists  in  the  form  of  white  crystal- 
line needles,  and  should  be  always  ordered  under  the 
name  of  acetyl  salicylic  acid  and  not  "aspirin,"  as  the  lat- 
ter is  a  trade-mark  name  and  would  subject  the  dentist 
or  his  patient  to  extra  expense. 

There  are  many  other  commercial  drugs  for  the  con- 
trol of  pain,  but  if  one  keeps  clearly  in  mind  these — 
opium  or  its  derivatives,  acetanilid  or  a.  salicylic — one 
has  practically  all  of  value ;  and  one  need  not  be  misled 
by  circulars  from  manufacturing  chemists  stating  that 
they  have  found  new  compounds  of  exceptional  value. 
That  sort  of  thing  is  continually  met  with  and  the  dentist 
or  medical  practitioner  who  uses  everything  called  to  his 
attention  is  apt  to  be  a  very  unscientific  man. 


ASTRINGENTS  141 

Pope's  lines 

' '  Be  not  the  first  by  whom  the  new  is  tried 
Nor  yet  the  last  to  lay  the  old  aside" 

constitute  a  very  good  rule  to  follow  in  the  use  of  these 
new  remedies.  Let  them  be  tried  in  the  laboratories ;  let 
the  physiological  experimenter  tell  what  these  products 
will  do  before  they  are  poured  into  the  patient's  system. 

ASTRINGENTS 

Next  in  the  consideration  of  drugs  are  Astringents. 
These  are  particularly  interesting  to  the  dental  profes- 
sion, because  they  are  used  locally  to  a  certain  extent. 
They  are  drugs  that  condense  or  draw  together  tissue, 
making  it  more  compact.  When  put  inside  of  the  mouth 
they  first  dry  up  all  the  natural  fluids. 

Astringents  are  of  two  classes,  vegetable  and  mineral. 
The  mineral  are  more  powerful;  they  include  salts  of 
copper,  particularly  sulphate  of  copper,  blue  vitriol, 
which  may  be  used  at  a  strength  of  one-half  to  two  per 
cent  for  an  astringent  wash. 

Alum.— Alum  is  a  very  common  agent  which  exists  in 
the  form  of  whitish  crystals,  not  very  soluble  in  water. 
Burnt  alum,  that  is  alum  deprived  of  its  water  of  crystal- 
lization, exists  in  the  form  of  a  coarse  powder,  and  is  an 
excellent  mineral  astringent. 

Acetate  of  Lead.— Acetate  of  lead,  or  sugar  of  lead, 
may  also  be  used  in  a  weak  solution  as  an  astringent 
agent,  but  it  is  not  commonly  so  used.  The  distinction 
between  an  astringent,  an  irritant  and  an  escharotic  is 
one  of  degree  rather  than  of  kind.  A  weak  escharotic 
may  be  astringent;  a  more  powerful  astringent  may  be 
an  irritant ;  a  more  powerful  irritant  an  escharotic. 

Tannic  Acid.— Tannic  acid  is  an  important  agent 
among  vegetable  astringents,  and  exists  as  a  powder  hav- 


L42  PHARMACOLOGY 

ing  a  bitter  taste,  fairly  soluble  in  water;  a  valuable 
astringent  for  the  general  purposes  for  which  astringents 
are  used.  It  may  be  used  at  any  strength  up  to  a  satu- 
rated solution  (as  much  as  water  will  take  up).  Tannic 
acid  is  made  from  nut-galls. 

Krameria.— Mention  might  be  made  here  also  of  kra- 
meria,  which  was  spoken  of  above  in  connection  with  cor- 
rect prescription  writing,  and  which  many  leaders  of  the 
dental  profession  value  as  an  astringent  more  than  al- 
most any  other. 

Witch  Hazel.— Then  we  have  hamamelis,  or  witch  hazel, 
— a  household  remedy  to  be  found  on  the  shelf  of  almost 
every  kitchen  in  New  England. 

Oak  Bark.— Quercus  or  oak  bark,  in  the  form  of  an  in- 
fusion, is  also  a  valuable  astringent. 

Caustics  or  Escharotics.— The  agents  used  to  destroy 
tissue  are  caustics  or  escharotics,  and  attention  is  called 
to  trichloracetic  acid,  which  exists  in  the  form  of  crystals 
fairly  soluble;  it  will  tend  to  destroy  neoplasms  pretty 
effectually. 

Lactic  Acid. — Pure  lactic  acid  is  a  powerful  eschar- 
otic.  Nitric  acid  is  the  caustic  par  excellence  among  min- 
eral acids;  applied  to  neoplasms  it  is  pretty  sure  death, 
but  it  is  somewhat  painful  in  its  action. 

Silver  Nitrate.  — Silver  nitrate  is  also  a  very  impor- 
tant agent,  and  is  classed  here  as  an  astringent  because  it 
is  that,  and  also  an  escharotic  to  a  certain  extent.  It  is 
soluble  in  water,  and  in  a  strength  of  from  one  per  cent 
to  ten  per  cent  silver  nitrate  is  one  of  the  most  valuable 
astringents  and  escharotics  which  we  have.  It  is  not 
painful  in  its  action  ordinarily.  It  has  been  used  largely 
in  the  dental  profession  for  treating  pulps.  Literature 
on  the  subject  tells  a  great  deal  about  nitrate  of  silver 
in  the  practice  of  dentistry. 

Arsenic. — Of  course  arsenic  is  one  of  the  escharotics 
used  for  the  devitalization  of  the  pulp  of  a  tooth;  most 
dentists  know  about  that. 


DISINFECTANTS  143 

DISINFECTANTS 

Disinfectants,  or  antiseptics,  are  next  to  be  considered. 
Strictly  speaking  there  is  a  difference  between  the  two. 
Anything  that  arrests  bacterial  action  is  an  antiseptic. 
It  may  not  be  a  germicide.  A  germicide  destroys  the 
power  of  the  germ:  while  an  antiseptic  renders  the  field 
less  fertile  for  the  growth  of  microorganisms.  The  nse 
of  antiseptics  is  very  extensive,  probably  more  extensive 
than  the  facts  of  the  case  warrant;  for  if  an  agent  suffi- 
cient to  destroy  the  germs  is  used  one  may  also  destroy 
the  tissue  itself. 

In  the  mouth  the  problem  of  asepsis  is  more  difficult 
than  on  the  surface,  because  the  oral  cavity  is  lined  with 
mucous  membrane  which  one  cannot  scrub,  and  it  is  more 
absorbent,  more  easily  affected  by  septic  material;  and 
so  the  hope  of  getting  an  antiseptic  mouth  is  pretty  faint. 
Practically  it  cannot  be  done.  What  can  be  done,  how- 
ever, is  to  get  a  fairly  clean  mouth ;  and  those  who  have 
worked  over  a  variety  of  mouths  know  how  desirable  it 
is  to  approximate  cleanliness  in  the  oral  cavity. 

Phenol.— There  are  several  agents  to  be  used  for  clean- 
liness. One  of  the  oldest  and  most  popular  is  phenol, — 
carbolic  acid  it  used  to  be  called.  Phenol  exists  as  crys- 
tals, which  liquefy  at  the  average  temperature  in  summer- 
time, and  is  a  powerful  germicide  and  disinfectant;  in 
sufficient  strength  it  will  destroy  the  germ  of  any  known 
disease  and  it  also  destroys  the  tissue.  Care  must  be 
taken  not  to  have  the  solution  too  strong.  A  3  per  cent 
solution  of  phenol  applied  to  the  hand  produced  gangrene 
in  one  case.  Of  course  in  that  case  evaporation  was  pre- 
vented and  the  continued  action  of  the  drug  maintained. 
Caution  must  be  used  in  regard  to  the  strength  of  phe- 
nol for  continuous  action, — one-half  to  one  per  cent  is 
strong  enough. 

Hydrogen  Peroxid.— Peroxid  of  hydrogen  is  H202,— 


144  PHARMACOLOGY 

a  watery  solution  of  the  gas  which  produces  effervescence 
when  brought  in  contact  with  albuminous  tissue,  liberat- 
ing oxygen. 

Bichlorid  of  Mercury.^ Bichlorid  of  mercury  is  one  of 
the  most  powerful  disinfectants.  It  exists  in  the  form 
of  a  powder, — in  strength  of  1  to  1000  to  1  to  5000. 

Alcohol.— Alcohol  is  an  antiseptic  of  some  value,— not 
powerful,  not  destructive  of  all  pathological  germs,  but 
it  dissolves  sebaceous  matter  and  helps  carry  off  secre- 
tions of  the  hand  or  flesh  anywhere,  making  it  fairly 
clean. 

Iodin.— Iodin  in  the  form  of  a  tincture  has  come  to  be 
one  of  the  most  highly  valued  antiseptics  which  we  have. 
A  monograph  by  a  surgeon  on  the  treatment  of  incised 
wounds  recently  stated  that  instead  of  opening  up  the 
wound  as  surgeons  formerly  did  they  deeply  probed  with 
gauze  soaked  in  tincture  of  iodin,  wiped  out  the  wound, 
and  got  as  good  results  as  if  they  had  opened  it  up  and 
drained  it.  Most  surgeons  use  iodin  in  the  tincture  form 
to  clean  the  field  of  operations. 

Creosote.— Creosote  is  an  antiseptic  of  some  value,  for- 
merly used  for  its  obtundent  properties. 

Boric  Acid.  — Boric  acid  used  in  a  saturated  solution 
is  a  valuable  antiseptic. 


DENTIFRICES 

Cleansing  Preparations. — In  regard  to  the  use  of  prepa- 
rations for  cleansing  the  mouth  and  the  teeth  there  are 
three  forms  ordinarily  in  use, — the  liquid  form,  the  pow- 
der form  and  the  paste  form;  each  man  has  his  favorite 
formulae  for  them.  It  seems  that  some  caution  should 
be  exercised  in  the  use  of  the  commercial  powders,  many 
of  which  are  dangerous  for  the  teeth  of  the  patient.  Not 
long  ago  a  series  of  articles  on  tooth  powders  showed  that 
many  of  the  commercial  tooth  powders   contain   chalk 


NOVOCAIN  AND  COCAIN  145 

enough  to  wear  off  the  enamel  of  the  teeth,  and  it  was 
demonstrated  that  one  could  take  a  live  tooth  and  cut  it 
off  with  that  powder  if  one  rubbed  long  enough.  A 
powder  which  has  been  tried  with  excellent  results  con- 
sists of  95  parts  caleium  carbonate,  about  3  parts  Castile 
soap  and  about  1  to  l1/.  parts  oil  of  birch  or  oil  of  pep- 
permint. 

A  preparation  for  a  liquid  mouth  wash  consists  of 
boric  acid  5  parts,  sodium  boras  18  parts,  resorcinal  18 
parts,  cologne  water  200  parts  and  sterile  water  500  parts. 
It  would  be  a  good  thing  for  dentists  to  prescribe  even 
toothpaste,  etc.,  for  their  patients,  as  it  would  save  the 
patients '  money  and  increase  their  confidence  in  the  den- 
tist. 

PHARMACOLOGY  OF  NOVOCAIN  AND  COCAIN 

Local  Anesthesia.— Local  anesthesia  is  of  somewhat 
modern  origin,  as  far  as  practical  results  are  concerned. 
It  was  the  dream  of  the  old  surgeons  that  anesthesia 
might  be  attained,  so  that  suffering  from  operations  on 
the  body  might  be  abolished.  The  subject  of  general 
anesthesia  has  been  handled  by  Dr.  Freeman  Allen  very 
thoroughly  and  satisfactorily.  Therefore  this  chapter 
will  be  confined  to  local  anesthesia. 

Previous  to  1884  attempts  to  produce  local  anesthesia 
were  somewhat  unsatisfactory.  Such  methods  were  re- 
sorted to  as  the  application  of  a  freezing  mixture  and 
the  cutting  off  of  circulation,  but  none  of  them  produced 
good  results.  Today  there  are  agents  which,  injected 
into  the  tissue  at  any  particular  point,  produce  a  degree 
of  anesthesia  sufficient  for  ordinary  surgical  purposes. 

Ethyl  Chlorid.— There  are  among  the  freezing  mix- 
tures the  one  known  as  ethyl  chlorid,  with  which  most 
dentists  are  familiar.  This  is  made  by  the  combined 
action  of  hydrochloric  acid  and  alcohol  and  exists  under 
ordinary  temperatures  as  a  gas,  but  is  easily  liquefied. 


146  PHARMACOLOGY 

Under  a  pressure  of  about  two  atmospheres  it  becomes  a 
clear,  colorless  liquid  of  a  rather  agreeable  odor  and 
sweetish  taste.  It  is  put  up  ready  for  use  in  tubes,  from 
which  the  liquid  can  be  released  under  suitable  pressure, 
when  it  immediately  vaporizes  and  produces  an  amount 
of  local  anesthesia  which  is  satisfactory.  If  it  is  neces- 
sary to  open  an  abscess  or  boil  with  the  ordinary  novo- 
cain and  cocain  solution,  the  skin  must  be  pierced,  which 
is  painful.  It  therefore  seems  the  perfection  of  technic 
to  throw  upon  the  skin  a  vapor  like  this,  which  renders  it 
practically  insensible,  and  then  the  needle  can  be  intro- 
duced without  pain. 

Cocain.  — Cocain  was  the  pioneer  agent  in  the  matter 
of  injected  substances  for  producing  local  anesthesia  and 
is  an  alkaloid  of  coca.  The  coca  plant  itself  may  be 
briefly  considered  here.  When  the  Spaniards  invaded 
Peru,  they  found  that  the  leaves  of  the  coca  plant  were 
used  to  a  very  large  extent  by  the  natives,  who  used 
them  so  that  they  could  go  without  food  much  longer; 
and  couriers  who  ran  long  distances  to  convey  tidings 
carried  coca  leaves  and  chewed  them  on  the  way  so  as  not 
to  be  obliged  to  stop  to  eat.  Undoubtedly  the  effect 
was  to  produce  a  certain  amount  of  numbing  of  the 
gustatory  nerves  so  that  the  man  did  not  sense  the  fact 
that  he  needed  food,  and  therefore  was  able  perhaps  to 
get  along  with  less  craving  for  the  natural  food  that 
he  would  ordinarily  take.  The  plant  temporarily  stimu- 
lates respiration  and  circulation,  so  that  under  the  influ- 
ence of  it  a  man  would  have  a  harder  pulse  and  would 
breathe  with  more  force.  It  produces  a  certain  amount 
of  exhilaration,  not  like  that  of  alcohol,  but  a  sense  of 
well-being  and  general  feeling  of  comfort.  This  is  prob- 
ably brought  about  by  sending  more  blood  to  the  brain. 
It  also  gives  a  sense  of  happiness.  It  tends  to  increase 
the  amount  of  urine,  but  the  amount  of  urea  is  lessened. 
It  checks  metabolic  waste.  Under  large  doses,  there  is 
a  feeling  of  incoordination,  and  some  delirium.    By  using 


NOVOCAIN  AND  COCAIN  147 

cocain  in  its  condensed  form  a  local  anesthesia  is  ob- 
tained. It  is  a  cerebral  and  cardiac  stimulant,  and  is 
used  to  dilate  the  pupil  of  the  eye.  In  large  doses  it 
causes  a  feeble,  intermittent  pulse,  a  jerky,  disturbed 
respiration  and  a  mental  condition  of  great  depression 
and  anxiety,  and  this  is  liable  to  come  on  very  suddenly. 

Danger  in  Administration. — The  patient  begins  to  act 
strangely;  his  pulse  is  quick,  intermittent  and  jerky;  he 
begins  to  get  very  anxious  and  may  say  "Doctor,  I  feel 
terribly.  I  think  I  am  going  to  die."  He  becomes  de- 
lirious and  may  get  convulsions.  The  thing  to  do  under 
such  circumstances  is  first  to  get  blood  to  the  brain.  This 
is  best  done  by  lowering  the  head  and  lifting  the  heels. 
Amyl  nitrite,  which  tends  to  flush  the  superficial  blood 
vessels,  may  be  used.  Another  treatment  of  this  condi- 
tion is  to  use  aromatic  spirits  of  ammonia.  This  seems 
to  act  as  a  stimulant  of  the  respiration  or  the  cardiac 
functions  pretty  promptly.  Strychnin  used  subcuta- 
neously  is  also  of  value.  The  dose  is  one-thirtieth  to  one- 
sixtieth  of  a  grain.  If  the  patient  stops  breathing  the 
only  thing  to  be  done  is  to  use  artificial  respiration.  That 
is  the  sheet-anchor  in  restoring  these  desperate  cases. 
Any  quick-acting  stimulant  is  of  value.  Sulphate  of 
strychnin  and  alcoholic  stimulants  act  much  in  the  same 
way  as  aromatic  spirits  of  ammonia. 

Effects  of  Cocain. — The  effect  of  cocain  is  to  produce 
local  anesthesia.  It  is  a  protoplasmic  poison.  The  pro- 
duction of  local  anesthesia  depends  to  a  certain  extent 
upon  the  paralysis  of  the  sensory  nerve  in  the  part  af- 
fected, and  this  is  ordinarily  increased  by  preventing  the 
return  of  the  venous  blood.  If  it  is  necessary  to  open  a 
finger,  it  is  better  to  put  a  rubber  band  around  it  and  by 
so  doing  the  solution  is  held  in  the  point  where  it  is 
wanted.  The  addition  of  some  agent  which  will  tend  to 
constrict  the  blood  vessels  is  the  modern  method  of  ad- 
ministration of  a  drug  like  cocain.  The  modus  operandi 
of  injecting  cocain  is  like  that  of  a  surgical  operation, 


148  PHARMACOLOGY 

and  should  be  treated  with  all  the  precaution  that  mod 
em  aseptic  surgery  demands. 

Aseptic  Precautions. —  When  the  drug  was  first  used 
there  were  horrible  cases  of  sepsis.  Cases  have  occurred 
where  the  jaw  bone  has  been  nearly  denuded  through 
necrosis  of  the  tissue  because  of  the  injection  of  cocain 
into  the  gum.  This  was  not  the  result  of  cocain  as  a  drug, 
but  the  result  of  a  septic  operation.  The  dentist  did  not 
understand  the  necessity  of  cleanliness,  and  introduced 
the  drug  into  the  gum  with  a  dirty  syringe  without  par- 
ticular care  as  to  whether  the  solution  was  sterile  or  not. 
The  things  to  consider  in  this  operation  are,  to  get  the 
field  as  sterile  as  possible,  to  cleanse  it  as  thoroughly  as 
may  be,  and  to  paint  it  lightly  with  tincture  pf  iodin. 

Validol. — There  is  an  agent  known  as  validol,  one  of 
those  preparations  apparently  made  up  of  menthol  and 
valerianic  acid  which  is  alleged  to  be  valuable  in  the  treat- 
ment of  cocain  poison.  However  it  seems  less  valuable 
than  the  agents  just  considered,  and  one  is  open  to  the 
criticism  of  furthering  a  commercial  enterprise  when 
prescribing  it. 

Disadvantages  of  Cocain. — There  have  been  various 
attempts  to  improve  upon  cocain,  for  the  reason  that  it 
produces  such  serious  results  in  some  cases,  and  also  for 
the  reason  that  it  is  not  easy  to  get  a  sterile  solution  of 
cocain.  It  does  not  stand  boiling  well.  Various  attempts 
have  been  made  to  get  agents  similar  to  cocain. 

Novocain.  — The  result  of  all  this  investigation  has 
given  us  what  we  know  as  novocain,  which  appears  to  be 
today  the  best  and  most  valuable  substitute  for  cocain. 
It  is  a  chemical  synthetical  compound  which  apparently 
does  what  cocain  does  and  with  less  danger.  It  is  claimed 
for  novocain  that  it  is  five  to  seven  times  as  safe  as  co- 
cain. With  common  doses  the  chances  for  serious  results 
are  about  one-sixth  as  large.  In  solution  in  water  it  can 
be  sterilized  by  boiling,  which  is  another  point  in  its  favor. 
It  is  usually  administered  with  epinephrin  and  easily 


NOVOCAIN  AND  COCAIN  149 

penetrates  the  mucous  surface.  Those  are  the  advan- 
tages of  hydrochloric!  of  novocain.  The  modus  operandi 
of  injecting  cocain  or  novocain  is  first  to  get  a  sterile  sur- 
face to  operate  on,  then  have  a  sterile  syringe.  The 
syringe  must  be  boiled  for  from  five  to  fifteen  minutes, 
using  a  normal  salt  solution  or  plain  sterile  water.  With 
these  precautions  the  dangers  of  novocain  are  practically 
eliminated.  For  five  years  there  has  not  been  a  single 
case  with  serious  results  from  the  injection  of  cocain  or 
novocain.  This  is  perhaps  largely  due  to  the  fact  that 
aseptic  methods  are  used  by  those  who  attempt  to  do  this 
sort  of  work.  The  strength  of  a  novocain  solution  may 
vary  from  one  to  ten  per  cent.  For  application  to  the 
nose  or  throat  a  solution  of  from  five  to  fifteen  per  cent 
is  recommended.  A  formula  is  here  given  for  making 
a  solution  for  external  use:  one  gram  (or  15  grains) 
with  100  c.c.  of  sterile  water;  solution  of  one  per  cent 
strength.  A  tablet  is  furnished  that  combines  epine- 
phrin,  about  0.005  of  a  grain  or  0.3  of  a  milligram,  with 
novocain,  0.33  of  a  grain.  One  of  these  tablets  in  a  cubic 
centimeter  of  water  gives  a  2  per  cent  solution. 

Aside  from  the  uses  of  ethyl  chlorid  and  novocain  for 
local  anesthesia,  there  are  the  aromatic  oil  series,  the 
oil  of  cloves,  etc.,  and  the  routine  treatment  ordinarily 
for  toothache  is  the  application  of  some  of  these  mild  lo- 
cal anesthetics,  especially  oil  of  cloves  and  creosote. 


CHAPTER  V 

PREOPERATIVE    AND    POSTOPERATIVE    MEDICAL    CARE 

OF  PATIENTS 

William  E.  Preble,  A.  B.,  M.  D. 

Medical  Care  of  Patient  Essential.— The  general  con- 
dition and  care  of  patients  before  operation  and  their 
care  immediately  after  operation  and  through  convales- 
cence are  factors  of  great  importance  in  surgery.  In 
many  cases  attention  or  lack  of  attention  to  what  I  may 
call  the  medical  care  of  the  surgical  patient  makes  the 
difference  between  life  and  death,  and  in  many  more 
cases,  between  a  short  and  a  long  convalescence.  In  the 
past  few  years  much  has  been  added  to  the  store  of 
knowledge  in  this  field  of  medicine.  The  general  princi- 
ples of  pre-operative  and  postoperative  care  are  the  same 
for  soldiers  as  for  civilians,  though  with  soldiers  in  the 
field  the  best  conditions  can  only  be  approximated,  partly 
because  much  of  the  surgery  is  emergency  work  and  part- 
ly because  the  best  facilities  for  work  are  unattainable. 

Pre-operative  Factors.— Factors  that  should  always  be 
considered  before  any  operation  is  undertaken  are  (a), 
the  presence  of  systemic  disease;  (b),  the  general  condi- 
tion of  the  patient  as  regards  fatigue,  starvation,  and 
mental  condition;  (<?),  the  psychic  factor  as  influenced  by 
bodily  comfort  and  surroundings;  and  (r/),  the  immedi- 
ate preparation  for  the  operation,  including  diet,  care  of 
bowels,  etc. 

COMPLICATING  SYSTEMIC  DISEASES 

Chronic  Conditions.— A  careful  and  complete  physical 
examination  should  always  be  made  before  any  operation 

150 


GENERAL  CONDITION  OF  PATIENT       151 

is  performed.  The  presence  of  acute  infections,  general 
or  local,  should  he  noted.  Chronic  infections  such  as 
tuberculosis  and  syphilis  should  be  ruled  out  for  obvious 
reasons.  The  condition  of  the  heart  should  be  noted,  al- 
though heart  lesions,  unless  badly  decompensated,  are 
not,  as  a  rule,  contra-indications  for  surgery.  Kidney 
disease  is  more  serious,  not  only  as  affecting  the  elimina- 
tive  functions  and  introducing  the  danger  of  uremia,  but 
also  because  many  patients  with  chronic  kidney  disease 
have  an  accompanying  acidosis  which  may  menace  the  life 
of  the  surgical  patient.  A  point  to  bear  in  mind  in  regard 
to  nephritis,  when  choosing  the  anesthetic,  is  that  nitrous 
oxid  raises  the  blood  pressure  30  to  50  mm.  and  may  be 
very  dangerous  for  patients  with  an  already  existing 
high  blood  pressure.  Diabetes  mellitus  and  Graves'  dis- 
ease should  always  be  ruled  out,  as  advanced  cases  would 
be  subjects  for  surgery  only  in  cases  of  grave  necessity. 
A  careful  examination  of  the  urine  should  always  be 
made  before  operation. 


GENERAL  CONDITION  OF  PATIENT 

Dangers  of  Acidosis  and  Acapnia.— The  condition  of 
the  patient  as  regards  exhaustion,  starvation,  insomnia 
and  great  emotion  or  excitement  is  particularly  impor- 
tant in  army  surgery,  as  all  of  these  conditions  may  be 
accompanied  by  an  acidosis  of  sufficient  severity  to  ren- 
der the  administration  of  an  anesthetic  very  dangerous 
to  the  patient.  Cotton  x  has  shown  that  extreme  excite- 
ment and  hysteria  may  induce  very  rapid  breathing  and 
thereby  cause  the  condition  known  as  acapnia,  due  to  a 
diminution  of  the  normal  percentage  of  carbondioxid  in 
the  blood.  As  carbondioxid  is  the  normal  stimulant  of 
the  respiratory  center,  inhalation  anesthesia  would  be 
very  dangerous  to  a  patient  in  this  condition,  as  respira- 
tory depression,  or  even  paralysis,  might  ensue.    In  lesser 


152  MUDICAL  CARE  OF  PATIENTS 

degrees  of  acapnia,  there  may  be  loss  of  venous  tone, 
which  may  be  an  important  factor  in  surgical  shock, 
and  loss  of  tone  of  the  stomach  and  bowel  musculature, 
predisposing  to  acute  dilatation  of  the  stomach  and  bow- 
el,— the  dreaded  paralytic  ileus.  A  few  hours'  sleep 
(giving  an  opiate  if  necessary)  would  restore  the  C02 
balance  to  normal,  and  eliminate  the  dangers  from 
acapnia. 


ACIDOSIS  AS  A  FACTOR  IN  SURGERY 

The  presence  of  an  acidosis,  or  acidemia,  may  be  of 
grave  import  to  a  surgical  patient.  Acidosis  is  an  abnor- 
mal increase  of  the  acid  element  of  the  blood.  It  is  prob- 
ably a  much  more  common  condition  than  is  generally 
realized,  and  is  undoubtedly  responsible  for  many  deaths 
in  surgical  practice.  In  the  past  few  years  much  valuable 
work  has  been  done  on  this  subject.  L.  J.  Henderson  2 
in  a  wonderful  series  of  articles  has  done  much  to  explain 
this  condition.  The  experimental  work  of  Crile 3  on 
acidosis  and  anesthesia,  of  Peabody  4  on  acidosis  in  car- 
diac and  renal  conditions  and  of  Marriott  and  Howland  5 
on  phosphate  retention  and  acidosis  in  nephritis  should 
be  given  careful  attention.  Whitney  c  gives  an  excellent 
summary  of  the  subject  in  a  recent  issue  of  the  Boston 
Medical  and  Surgical  Journal.  A  brief  statement  of  the 
main  factors  in  this  condition  may  be  of  some  value  in 
explaining  its  importance  in  surgery. 

Balance  of  Acids  and  Alkalies 

Metabolism.— Normally,  the  balance  of  acids  and  al- 
kalies of  the  blood  is  maintained  at  a  very  constant 
level.  The  chief  constituents  affecting  the  reaction  of 
the  blood  are  the  alkaline  radicals,  Na,  Ca,  Mg,  and  K, 
and  the  phosphates,  carbonates,  and  free  CO.,.     There 


ACIDOSIS  AS  A  FACTOR  IN  SURGERY     153 

are  other  factors,  but  they  are  relatively  unimpor- 
tant. 

When,  for  any  reason,  there  is  an  increase  in  the  acid 
content  of  the  blood,  there  is  a  general  shifting  of  hydro- 
gen ions.  The  phosphates  are  changed,  some  of  the  alka- 
line phosphate  becoming  acid  phosphate;  some  of  the 
carbonate  becoming  bicarbonate;  and  some  of  the  bicar- 
bonate loses  its  alkali,  and  free  carbonic  acid  is  released. 
The  increase  of  carbonic  acid  in  the  blood  stimulates 
respiration  and  the  increased  ventilation  quickly  reduces 
the  COo  percentage  in  the  blood  to  normal,  provided 
the  addition  of  acid  to  the  blood  is  not  too  great.  The 
kidneys  are  also  an  important  factor  in  maintaining 
the  acid  content  of  the  blood  at  a  constant  level,  as  they 
have  the  power  of  excreting  either  acid  salts  or  alkaline 
salts  as  may  be  necessary  to  maintain  the  normal  bal- 
ance. 

This  mechanism  is  ordinarily  very  efficient,  but,  in  ex- 
treme cases,  the  acid  production  may  be  so  great  that  the 
lungs  and  kidneys  are  unable  to  keep  the  acid  content  of 
the  blood  below  normal  limits ;  the  CO.,  first  stimulates, 
then  depresses,  finally  paralyzes  the  respiratory  center, 
and  death  ensues  from  respiratory  paralysis. 

Acids  are  formed  normally  to  some  extent  in  the  body 
metabolism.  Among  foods,  meat  and  most  cereals  pro- 
duce acids ;  and  most  fruits  and  vegetables  produce  alka- 
lies.7 The  organic  acids  in  oranges,  lemons,  grapefruit, 
tomatoes,  etc.,  form  alkaline  carbonates  when  absorbed, 
and  help  neutralize  the  acids  in  the  blood.  Vigorous 
exercise,  exhaustion,  starvation  and  insomnia  cause  an 
abnormal  acid  production. 

Incidence  of  Acidosis.— Acidosis  may  develop  with  de- 
compensated hearts,  in  nephritis,  diabetes  mellitus,  with 
certain  infections  (especially  pneumonia),  during  inhala- 
tion anesthesia,  and  after  surgical  operations ;  hence  the 
importance  of  the  condition  in  surgery.  The  withhold- 
ing of  food  immediately  before  and  for  many  hours  after 


154  MEDICAL  CARE  OF  PATIENTS 

operation,  together  with  the  anesthetic,  may  cause  suffi- 
cient increase  in  acid  production  to  cause  respiratory 
paralysis  and  death.  In  other  cases  an  acidosis  may  be 
the  cause  of  persistent  postoperative  vomiting,  and  be 
conducive  to  shock.  Patients  with  decompensated  hearts, 
or  with  impaired  renal  function,  should  be  the  objects  of 
especial  care  to  avoid  the  dangers  of  acidosis. 

Treatment  of  Acidosis 

Alkalies.— If  the  kidney  function  is  not  impaired,  alka- 
lies may  be  administered  freely,  together  with  plenty  of 
fluid,  but  if  the  kidneys  are  diseased  and  cannot  excrete 
the  salts,  care  must  be  taken  not  to  give  too  much  alkali, 
as  too  great  a  concentration  of  salts  in  the  blood  is  dan- 
gerous. In  any  case,  the  administration  of  alkalies 
should  cease  when  the  normal  balance  is  restored — i.e., 
when  the  urine  is  neutral  or  very  slightly  alkaline,  as  pro- 
longed use  of  alkalies  causes  lassitude  and  general  weak- 
ness. 

Excess  Alkali  Diet.— Mild  cases  of  acidosis  should  be 
treated  by  regulating  the  diet,  if  time  and  conditions  will 
permit.  Practically  all  of  our  ordinary  vegetables  and 
fruits  (except  prunes,  plums,  and  cranberries)  give  an 
alkaline  balance  when  ingested,  the  citrous  fruits 
(oranges,  lemons,  grapefruit,  etc.)  being  particularly 
valuable,  as  the  juice  can  be  given  in  pleasant  drinks. 
Beans,  peas,  carrots,  beets,  potatoes,  tomatoes  and  mel- 
ons all  give  considerable  excess  alkali.  Milk  has  very 
little  excess  alkali,  but  with  limewater  added  makes  an 
excellent  food  for  these  patients. 

The  meats  all  give  an  excess  of  acid,  lean  pork  con- 
taining the  least  acid,  and  chicken  the  largest  amount. 
The  common  cereals  and  breadstuffs  all  give  an  excess 
of  acid,  rice  the  lowest  and  oatmeal  the  highest.  Eggs 
have  a  fairly  high  excess  acid.  The  diet  for  patients  with 
an  acidosis   should  contain  plenty  of  fruit    (especially 


THE  PRE-OPERATIVE  MEASURES         155 

orange,  lemon  and  grapefruit  juice),  cream  or  milk  soups 
with  vegetables,  such  as  potatoes,  carrots,  peas,  beans, 
spinach,  lettuce,  etc.,  and  milk  and  cream  with  limewater 
or  French  Vichy  added.  It  may  be  necessary  to  give 
some  sugar  in  order  to  help  restore  to  normal  the  fat 
— carbohydrate  metabolism. 

Gruels  made  of  cereals,  meat  broths,  and  eggs,  or  egg 
drinks,  are  contra-indicated. 

The  diet  should  contain  plenty  of  fluid,  to  assist  the 
kidneys  in  eliminating  the  excess  of  acid  salts,  and 
the  patient  should,  of  course,  have  plenty  of  fresh  air 
to  enable  the  lungs  to  excrete  the  excess  of  carbonic 
acid. 


THE  PSYCHIC  PREPARATION   FOR   SURGICAL 
OPERATIONS 

To  the  ordinary  person,  a  surgical  operation  has  a  pe- 
culiar horror.  This  feeling  of  fear  may  be  so  intense  as 
to  be  a  factor,  not  only  in  the  comfort  of  the  patient,  but 
even  in  the  result  of  the  operation,  as  has  been  demon- 
strated by  Crile.  Much  can  be  done  in  the  way  of  reas- 
surance if  the  nature  of  the  operation  ie  explained,  and 
if  the  patient  is  told  of  the  very  low  mortality  accom- 
panying anesthesia  and  most  surgical  operations.  The 
patient  should  have  a  good  sleep  the  night  before  the 
operation,  even  if  an  opiate  is  necessary.  It  is  very  de- 
sirable for  the  patient  to  go  to  the  operating  table  with 
confidence  in  the  surgeon  and  with  nerves  well  under 
control. 

THE  PRE-OPERATIVE  MEASURES 

Diet.  — Ordinarily,  the  usual  full  diet  should  be  given 
up  to  the  night  before  the  operation.  If  the  digestive 
tract  is  normal,  it  should  be  remembered  that  the  stom- 


156  MEDICAL  CAEE  OF  PATIENTS 

ach  will  empty  itself  in  four  to  six  hours  or  less,  and 
the  small  bowel  in  about  eight  to  twelve  hours,  so  that 
if  the  patient  does  not  take  breakfast,  the  colon  is  really 
the  only  part  of  the  gastro-intestinal  tract  that  needs  at- 
tention. An  enema  the  night  before  and  another  in 
the  morning  before  the  operation  is  sufficient  prepara- 
tion. 

Catharsis.  — Of  course  if  the  intestinal  tract  is  not  act- 
ing normally,  a  cathartic  may  be  required  the  day  be- 
fore the  operation.  It  should  be  remembered,  however, 
that  a  perfectly  well-behaved  bowel  may  have  its  func- 
tioning ability  very  much  impaired  by  drastic  catharsis. 
Even  if  the  operation  is  to  be  a  laparotomy,  the  attempt 
to  turn  the  bowel  inside  out,  with  the  accompanying  irri- 
tation and  congestion  of  the  mucous  membrane,  can  only 
do  harm.  Excessive  irritation  is  conducive  to  later  pa- 
ralysis, and  an  absolutely  empty  bowel  is  apt  to  fill  with 
gas. 

Complicating  Conditions 

Diabetes — Nephritis.— If  the  patient  has  systemic  dis- 
ease, much  more  careful  preparation  may  be  necessary. 
Diabetics  should  not  be  operated  until  they  are  free  from 
sugar  and  acidosis.  Patients  with  chronic  nephritis 
should  be  put  on  a  low  protein  diet  with  plenty  of  fluid 
for  several  days  before  the  operation,  and  it  should  be 
remembered  that  many  nephritics  have  an  acidosis  which 
may  not  show  in  the  urine.  A  safe  procedure  is  to  give 
the  excess-alkali  diet  mentioned  above.  Three  pints  of 
milk  will  contain  the  necessary  daily  amount  of  protein, 
— about  fifty  grams. 

Cardiac  Conditions. — As  has  been  mentioned  before, 
compensated  heart  lesions  do  not  as  a  rule  contra-indicate 
operation.  If  the  heart  is  decompensated  and  there  is 
edema  present,  several  days  on  the  Karell  diet  will  be 
beneficial.  Karell8  published  his  "cure"  in  1866.  It 
consists  of  200  c.  c.  of  milk  at  8  A.M.,  12  M.,  4  P.M.  and 


POSTOPERATIVE  CARE  157 

8  P.M.  The  patient  is,  of  course,  kept  flat  in  bed,  and  no 
other  food  or  drink  is  given.  Drugs  may  be  used  as  indi- 
cated. Digitalis  may  be  advisable  to  slow  the  pulse  and 
opium  may  be  necessary  to  quiet  the  patient  and  stimu- 
late the  heart. 

Asthenic  Conditions.— Army  surgeons  may  frequently 
be  obliged  to  operate  on  men  who  are  much  fatigued,  im- 
properly nourished,  starved  even,  or  in  a  state  of  great 
excitement.  It  is  well  to  bear  in  mind  the  fact  that  all 
of  these  conditions  may  be  accompanied  with  an  acido- 
sis of  such  a  degree  that  the  anesthetic  may  readily  pro- 
duce respiratory  depression  and  paralysis,  or  a  post- 
operative acidosis  with  the  accompanying  persistent 
vomiting  may  produce  profound  shock.  If  the  condition 
of  the  patient  permits,  the  operation  should  be  post- 
poned twenty-four  to  forty-eight  hours  to  allow  nor- 
mal metabolism  to  become  reestablished.  The  alkali  diet 
mentioned  above,  with  a  good  sleep  and  plenty  of  water, 
will  produce  the  desired  result.  If  it  is  impossible  to 
postpone  the  operation,  alkalies  should  be  introduced. 
Fischer's  °  solution  by  rectum — 500  c.c.  every  four  hours 
— is  excellent  to  terminate  an  acidosis  quickly.  The  im- 
portance of  sleep  and  the  general  comfort  of  the  patient, 
mental  as  well  as  physical,  have  already  been  discussed 
above. 

POSTOPERATIVE  CARE 

Nausea  and  Vomiting.— Immediately  after  the  opera- 
tion, if  the  anesthetic  be  ether  or  chloroform,  there  is 
usually  more  or  less  nausea  and  vomiting.  In  some 
cases,  the  vomiting  is  persistent,  and  may  become  a 
very  grave  and  troublesome  complication.  Probably  the 
anesthetic  is  a  cause  in  many  cases,  from  direct  irrita- 
tion of  the  gastric  mucosa. 

Some  cases  undoubtedly  owe  the  persistent  vomiting 


158  MEDICAL  (JAKE  OF  PATIENTS 

to  an  acidosis.  As  pointed  out  above,  the  patient  may 
have  a  slight  acidosis  before  the  operation,  and  the 
anesthetic  and  operation  increase  the  acid  content  of  the 
blood  beyond  the  point  at  which  the  lungs  and  kidneys 
can  easily  maintain  the  balance.  In  these  cases,  again, 
the  condition  should  be  avoided  by  proper  care  before 
the  operation. 

It'  in  spite  of  pre-operative  precautions  the  patient 
develops  an  acidosis,  the  most  efficient  emergency  treat- 
ment is  Fischer's  solution  by  rectum,  and  fruit  juices  by 
mouth.  As  soon  as  the  patient  can  eat,  the  alkali  diet 
should  be  given.  It  should  be  remembered  that  alkalies 
should  not  be  given  in  large  amounts  after  the  reaction 
of  the  urine  is  neutral. 

Careful  Anesthesia  Necessary.— Another  factor  may  be 
loss  of  tone  of  the  gastro-enteric  musculature,  with  the 
accompanying  paresis  and  perhaps  dilatation  of  stomach 
and  bowel.  Acapnia  may  be  a  factor  in  these  cases,  due 
to  the  rapid  breathing  while  under  the  anesthetic,  with 
the  resulting  diminution  of  the  carbondioxid  content  in 
the  blood.  The  treatment  here  is  prophylaxis.  The  an- 
esthetist should  give  the  smallest  necessary  amount  of 
the  anesthetic,  and  should  give  it  in  such  a  manner  as  to 
avoid  the  so-called  excitement  stage.  A  certain  amount 
of  rebreathing  permits  the  patient  to  conserve  his  car- 
bondioxid. 

Postoperative  Renal  Irritation.— Tn  all  cases  follow- 
ing ether  and  chloroform  anesthesia,  fluids  should  be 
given  freely  to  minimize  the  irritation  to  the  kidneys  by 
the  anesthetic.  The  frequency  with  which  albumin,  and 
in  some  cases  blood  and  casts,  are  found  in  the  urine 
after  operations  indicates  that  the  condition  of  the  kid- 
neys should  be  carefully  watched,  and  the  irritation  re- 
duced to  a  minimum.  The  functioning  ability  of  the 
kidneys  is  impaired  by  ether  (and  probably  by  chloro- 
form) in  direct  ratio  to  the  depth  of  anesthesia.  If 
fluids  cannot  be  taken  in  sufficient  quantities  by  mouth 


SUEGICAL  SHOCK  159 

they  may  be  administered  by  rectum,  subcutaneously  or 
intravenously. 

SURGICAL  SHOCK 

Crile's  Work. — The  factors  that  produce  the  condition 
known  as  shock  are  not  well  understood.  Crile  has  tried 
to  explain  the  condition  as  due  to  overstimulation  of  the 
afferent  nerves,  and  has  tried  to  block  the  impulses  from 
the  operating  field  by  injections  of  local  anesthetics, — 
his  famous  anoci-association  method. 

Cannon's  Theory. — Cannon,10  in  his  last  Shattuck  Lec- 
ture, summarizes  in  his  usual  masterly  way  the  clinical 
signs  and  symptoms  of  shock,  and  explains  the  condition 
as  due  to  (a)  stimulation  of  the  vasomotor  center  by 
deficient  circulation;  (b)  constriction  of  the  peripheral 
arteries;  and  (c)  "trapping"  of  the  blood  in  the  splanch- 
nic vessels;  because  of  (d)  constriction  of  the  branches 
of  the  portal  vein  in  the  liver.  He  calls  attention  to  the 
fact  that  the  portal  vein  lies  between  two  capillary  re- 
gions,— the  capillaries  in  the  stomach,  bowels,  pancreas, 
and  spleen,  and  the  capillaries  of  the  liver.  There  is  a 
drop  in  the  blood  pressure  from  about  120  mm.  in  the 
aorta,  to  10  or  12  mm.  in  the  portal  vein,  and  a  further 
drop  to  practically  zero  in  the  vena  cava.  If  the  vessels 
in  the  liver  are  constricted,  there  may  not  be  sufficient 
force  behind  to  drive  the  blood  through,  hence  the  accu- 
mulation in  the  splanchnic  area.  The  problem  in  shock, 
then,  is  to  get  the  blood  out  of  this  area  and  back  into 
the  general  circulation. 

Cannon  thinks  that  the  usual^  methods  of  treating 
shock,  i.e.,  raising  the  foot  of  the  bed,  bandaging  the  ex- 
tremities, pressure  on  the  abdomen,  etc.,  are  ineffectual. 
The  same  is  true  of  the  usual  drug  treatment.  Adrenalin 
is  contra-indicated,  because  it  contracts  the  splanchnic 
arterioles  and  distends  arterioles  elsewhere, — an  effect 


160  MEDICAL  CARE  OF  PATIENTS 

just  the  reverse  of  that  desired.  He  suggests  the  intra- 
abdominal use  of  pituitrin,  which  might  constrict  the 
arterioles  outside  the  liver,  and  drive  the  blood  through 
the  liver. 

Work  of  Porter. — Porter,11  who  has  written  a  most  in- 
teresting and  valuable  series  of  articles  on  shock  based 
on  experience  at  the  front  in  France,  has  used  carbon- 
dioxid  inhalations  to  increase  respiration,  and  to  draw 
the  blood  through  into  the  lungs.  He  says  the  systolic 
pressure  may  be  raised  from  15  mm.  to  30  mm.  by  this 
method.  The  patient's  head  is  put  in  a  closed  box,  and 
the  C02  introduced.  Simply  letting  the  patient  rebreathe 
his  own  breath  in  the  box  helps  to  conserve  the  C02  con- 
tent, and  induce  deeper  breathing. 

It  should  be  remembered  in  this  connection  that  too 
great  a  C02  content  acts  as  a  respiratory  depressant 
and  eventually  paralyzes  the  respiratory  center. 

Fat  Emboli  and  Shock.— Porter  thinks  that  fat  emboli 
may  be  the  cause  of  shock  in  some  cases,  as  soldiers 
with  severe  injuries  to  the  large  bones  are  more  likely 
to  get  in  a  state  of  shock  than  patients  with  other  in- 
juries. He  supports  this  theory  with  some  experimental 
work  on  rabbits  injected  intravenously  with  olive  oil. 
The  rabbits  so  injected  become  profoundly  shocked. 

More  work  on  the  whole  subject  of  shock  is  necessary 
before  we  can  thoroughly  understand  the  condition,  or 
develop  an  effective  therapy. 


POSTOPERATIVE  DIET 

Early  Nutrition.— It  is  advisable  to  avoid  too  long  a 
period  of  starvation  or  semi-starvation  after  the  opera- 
tion. Water  should  be  given  freely,  but  in  small  quanti- 
ties, as  soon  as  the  patient  is  out  of  ether.  If  the  patient 
happens  to  be  undernourished,  nutrient  enemata  may  be 
given  a  few  hours  after  the  operation,  and  liquid  foods 


POSTOPERATIVE  CATHARSIS  161 

by  mouth  may  be  given  as  soon  as  the  nausea  and  vomit- 
ing cease.  Fruit  juices,  milk  with  lime  water  added, 
milk  and  cream  soups  with  potato  and  other  soft  vege- 
tables added,  are  indicated. 

If  there  is  any  question  of  acidosis,  broths,  eggs,  and 
cereal  gruels  are  contra-indicated.  If  the  operation  is 
not  abdominal,  ordinary  diet  may  be  resumed  as  early 
as  the  day  after  the  operation. 

Distention  with  Gas.— If  there  is  much  distention  of 
the  bowels  with  gas,  care  must  be  used  to  avoid  the  foods 
that  are  apt  to  ferment,  and  aerated  drinks  of  any  kind 
are  of  course  contra-indicated  as  increasing  the  amount 
of  gas.  Egg  albumen,  broths,  and  milk  are  indicated.  If 
sugar  is  given,  it  should  be  milk  sugar,  or  some  maltose 
preparation,  as  these  ferment  less  easily. 

Paresis  of  Bowel.— If  there  is  paresis  of  the  intestinal 
tract  with  acute  dilatation  of  stomach  and  bowel,  lavage 
is  indicated,  and  should  be  repeated  every  three  or  four 
hours  till  the  vomiting  ceases.  It  should  be  remembered 
that  acidosis  is  frequently  a  cause  of  persistent  vomiting, 
and  in  these  cases  the  urine  should  always  be  tested  for 
acetone  and  diacetic  acid. 


POSTOPERATIVE  CATHARSIS 

Cascara.— If  the  operation  is  not  abdominal  the  bowel 
should  be  restored  to  its  normal  routine  as  soon  as  pos- 
sible after  the  operation.  Mild  cathartics,  e.g.  Cascara 
pill  gr.  iii  t.i.d.,  in  divided  doses  are  preferable  to  larger 
doses  of  physic.  If  the  operation  is  abdominal,  and 
there  is  much  manipulation  of  the  gut,  it  should  be  re- 
membered that  the  bowel  will  not  return  to  its  normal 
condition  of  tonicity  for  at  least  twenty-four  hours,  and 
cathartics  of  any  kind  would  not  be  indicated  for  at  least 
that  period.  There  can  be  no  general  rule  that  is  appli- 
cable to  all  cases. 


L62  MEDICAL  CAEE  OF  PATIENTS 

Cascara  in  divided  doses  would  be  better  than  the  usual 
calomel  and  oil,  and  would  avoid  all  danger  of  mercurial 
poisoning,  which  occasionally  occurs  in  cases  with  stasis 
or  obstruction.  Enemata  can  usually  be  relied  on  to 
empty  the  colon,  unless  there  is  paresis.  Pituitrin  is 
valuable  in  sonic  cases  of  distention. 


CONVALESCENT  CARE 

Caloric  Intake. — The  caloric  intake  of  the  patient 
should  be  carefully  watched.  About  1500  calories  should 
be  approximated  while  the  patient  is  in  bed,  and  this 
should  be  increased  to  2500  or  3000  calories  after  the 
patient  is  up.  If  the  patient  is  emaciated,  even  more 
nourishment  should  be  given.  A  well-balanced  diet 
should  be  prescribed.  Under  any  condition,  a  minimum 
of  50  grams  of  protein  should  be  given  daily,  and  after 
the  patient  is  up  this  should  be  increased  to  about  100 
grams.  Sufficient  fruit  and  vegetables  should  be  given  to 
move  the  bowels  without  a  cathartic,  and  to  give  the 
body  the  necessary  salts  for  the  body  chemistry.  The 
fat  and  carbohydrate  intake  should  be  varied  according 
to  the  state  of  nutrition  of  the  patient, — fat  patients  be- 
ing allowed  less  fat  and  high  percentage  carbohydrate 
foods  than  thin  ones.  It  should  be  remembered  that 
the  appetite  is  a  very  poor  index  of  the  needs  of  the  pa- 
tient, and  this  is  just  as  true  in  convalescence  as  when 
the  patient  is  in  bed. 

Intake  of  Fluids.— The  fluid  intake  is  also  important. 
Insufficient  fluid  puts  extra  work  on  the  kidneys  and  is 
conducive  to  constipation.  From  2000  to  3000  c.  c.  should 
be  ingested  daily  by  the  average  person.  Careful  atten- 
tion to  the  diet  is  the  most  important  single  factor  in  put- 
ting the  patient  speedily  into  good  condition. 


CONVALESCENT  CARE  163 

References 

1.  Cotton.     Acapnia :  Its  Surgical  Importance,  Boston 

Med.  and  Surg.  Jour.,  Sept.  26,  1912,  432. 

2.  Henderson.    The  Theory  of  Neutrality  Regulation  in 

the  Animal  Organism,  Am.  Jour.  Physiol.,  1908, 
xxi,  427. 

Henderson  and  Palmer.  On  the  Intensity  of  Uri- 
nary Acidity  in  Normal  and  Pathological  Condi- 
tions, Jour.  Biolog.  Chem.,  1913,  xiii,  No.  4. 

Palmer  and  Henderson.  Clinical  Studies  on  Acid 
Base  Equilibrium  and  the  Nature  of  Acidosis, 
Arch.  Int.  Med.,  1913,  xiv,  153. 

Palmer  and  Henderson.  A  Study  of  the  Several 
Factors  of  Acid  Excretion  in  Nephritis,  Arch.  Int. 
Med.,  1915,  xvii,  109. 

3.  Crile.     Experimental  Research  into  the  Nature  of 

Nitrous  Oxid  and  Ether  Anesthesia,  Jour.  A.M. A., 
Dec.  16,  1916,  1830. 

4.  Peabody.      Studios    on    Acidosis    and    Dyspnea    in 

Renal  and  Cardiac  Conditions,  Arch.  Int.  Med., 
1914,  xiv,  236. 

5.  Marriott  and  Howland.     Phosphate  Retention  as  a 

Factor  in  the  Production  of  Acidosis  in  Nephritis, 
Arch.  Int.  Med.,  1916,  xviii,  708. 

6.  Whitney.    Acidosis:  A  Summary  of  Recent  Knowl- 

edge, Boston  Med.  and  Surg.  Jour.,  Feb.  15,  1917, 
225. 

7.  Sherman  and  Gettler.    Jour.  Biol.  Chem.,  1912,  xi, 

323. 

8.  Karell.    Arch.  Gen.  de  Med.,  1866,  viii,  513. 

9.  Fischer.    Edema  and  Nephritis,  John  Wiley  &  Sons, 

Inc.,  New  York,  1915,  p.  566. 

10.  Cannon.     The  Physiological  Factors  Concerned  in 

Surgical  Shock,  Boston  Med.  and  Surg.  Jour., 
June  21,  1917,  859. 

11.  Porter.     Observations  on  Shock  at  the  Front,  Bos- 


164  MEDICAL  CARE  OF  PATIENTS 

ton  Med.  and  Surg.  Join-.,  Doc.  14, 1916, 1854;  ibid., 
Feb.  15,  11)17,  248;  ibid.,  May  17,  1917,  699;  ibid., 
Sept.  6,  1917,  326. 


CHAPTER  VI 

MAXILLARY  FRACTURES  (MECHANICAL) 

Harold  DeWitt  Cross,  D.M.D. 

History  and  Construction  of  Appliances  for  the  Treat- 
ment of  Maxillary  Fractures 

This  chapter  will  deal  entirely  with  appliances,  leav- 
ing everything  in  the  nature  of  surgical  features  for  the 
other  part  of  the  course.  Unfortunately,  in  presenting 
this  subject,  the  writer  cannot  utilize  any  models  from 
his  own  cases,  on  account  of  being  out  of  active  practice 
for  over  five  years,  as  these  models  belong  to  the  Infir- 
mary where  he  was  previously  connected.  So  that  in  or- 
der to  present  the  subject  it  will  be  necessary  to  depend 
upon  his  own  experience  and  upon  such  textbook  draw- 
ings as  he  found  most  applicable  to  the  illustration  of  the 
various  cases. 

TREATMENT   OF   MAXILLARY   FRACTURES 

History.— First  in  order  will  be  considered  the  history 
of  appliances  for  the  treatment  of  fractures  of  the  jaw. 
This  is  not  merely  for  the  purpose  of  giving  interest  or 
entertainment  or  even  the  history  of  the  appliance  used 
in  the  treatment  of  these  fractures,  but  to  familiarize 
the  reader  with  the  various  methods  which  others  have 
used  and  which  are  still  in  use,  with  such  modifications 
and  adjustments  as  each  individual  case  seems  to  de- 
mand.    It  is  important  to  realize  that  there  is  in  the 

165 


166     MAXILLARY  FRACTURES  (MECHANICAL) 

war  today  practically  no  new  appliance,  used  in  the  treat- 
ment of  maxillary  fractures,  which  differs  materially 
from  those  to  be  shown  under  the  head  of  "history." 
The  appliances  look  a  little  different,  they  are  con- 
structed out  of  different  material,  they  are  modified  in 
this  way  and  that  way,  but  the  fundamental  principles 
underlying  the  application  and  purpose  are  taken  directly 
from  some  of  these  original  ones. 

Primitive  Methods.— From  this  standpoint  it  will  be 
readily  seen  how  important  it  is  that  one  should  become 


Fig.  44. — Chopart 's  Appliance.     (Kingsley.) 


familiar  with  these  original  appliances,  for  during  the 
last,  twenty-five  years  there  has  been  no  particularly 
new  appliance  brought  out.  In  beginning  the  history  of 
these  appliances  probably  the  earliest  mention  which  it  is 
possible  to  find  is  by  Hippocrates  in  the  fifth  century 
B.C.,  where  mention  is  made  of  the  treatment  of  frac- 
tured jaws  by  means  of  ligatures  passed  around  the 
teeth.  The  earliest  definite  appliance  to  which  attention 
will  be  called  is  one  that  was  used  by  Chopart  in  1780, 
and  which  appears  in  Kingsley 's  "Oral  Deformities" 
(Figure  44).  It  will  be  noted  that  this  is  a  rather 
crude  appliance  consisting  principally  of  a  semicircular 
piece   of   thin   iron   resting   on   the    ends    of   the   teeth 


TREATMENT  OF  MAXILLARY  FRACTURES     167 


and  a  piece  of  wood  beneath  the  chin,  and  from  the 
exposed  portion  on  either  side  an  ordinary  machinist's 
clamp  is  used  to  bind  the  portion  in  the  mouth  to  the 
chin  piece.  One  sees  appli- 
ances of  this  nature  still  used 
occasionally  with  fairly  suc- 
cessful results. 

Bone  Wiring.  —  An  old 
method  of  wiring  the  bone 
was  one  in  which  a  wire  was 
passed  through  holes  drilled 
in  the  bone  itself  and  the 
ends  wound  upon  a  split  in- 
strument, making  a  coil  on 
either  end  to  prevent  the  wire 
from  slipping  out  and  to  force 
the    ends   of   the   bone   more 

closely  together.  This  was  sometimes  modified,  as  in 
Figure  45  (Kingsley),  by  passing  the  wire  down  oppo- 
site the  root  of  the  tooth  and  the  other  end  through  a 


Fig. 


—Bone  AViring:      Modi- 
fied   Form.      (Kingsley.) 


Fig.   46. — Ligature   Method:      Hammond   Modification.     (Kingsley.) 

hole  in  the  bone,  twisting  the  ends  in  the  same  man- 
ner. 

Ligature  Method.— The  next  adaptation  and  modifica- 
tion of  this  method  was  the  use  of  pins  by  a  Mr.  Wheel- 


168    MAXILLABY   FRACTURES  (MECHANICAL) 

house  of  Leeds.  Holes  were  drilled  through  the  entire 
body  of  bone  from  the  lingual  to  the  labial  side,  and 
flat-headed  pins  were  passed  through  these  holes  and  the 

ends  bent  over,  providing 
hooks  around  which  a  wire  lig- 
ature was  passed.  This  method 
was  the  forerunner  of  the  de- 
vice in  which  patella-hooks 
^r-j^Q  were  used,  which  were  placed 

in  holes  drilled  in  the  bone  and 
ligatured  in  a  similar  manner 
to  the  last  method. 

The  Hammond  splint  shown 
in  Figure  254  (Kingsley)  and 
applied  to  a  model  on  the  pre- 
ceding page  is  an  adaptation 
and     extension     of     the     liga- 

Fig.     47. — Ligature     Method:  ,,      -.      ,1  •  v    ,  _ 

Merged  Clamps.  (Kingsley.)  ture  method,  this  Splint  Con- 
sisting of  a  fairly  heavy  wire, 
from  No.  16  to  No.  14  gauge,  extending  entirely  around 
the  labial  and  lingual  surfaces  of  the  teeth,  being  joined 
to  make  one  continuous  wire.  Separate  loops  of  a  smaller 
ligature  wire  were  placed  around  individual  teeth  over 


Fig.  48. — Metal  Splint  Devised  by   Moon.      (Kingsley.) 


the  wire  on  one  side  and  around  the  teeth  over  and  under 
the  wire,  between  the  teeth  on  the  other  side  and  twisted 
firmly  into  position.  This  forms  a  very  useful  attach- 
ment for  such  cases  as  show  a  displacement  only  in  a 


TREATMENT  OF  MAXILLARY  FRACTURES     169 


horizontal  plane. 
Other  fractures 
where  the  dis- 
placement is  in 
a  vertical  plane 
are  not  so  read- 
ily held  in  posi- 
tion by  this 
method. 

F  i  g  u  re  47 
(K  i  n  g  s  I  e  y) 
shows  an  appli- 
ance where  two 
clamps  are 
merged  into  one 

so  far  as  the  attachment  of  the  chin  piece  is  concerned, 

and  the  upper  portions 


Fig 


Modified  Metal  Splint.     (Kingsley.) 


firmly   attached   to 
iron    splint    inside 


Fig. 


50. — Modified   Metal   Splint. 
(Kingsley.) 


are 
the 

the  mouth.  The  chin 
piece  is  hollowed  out  to 
provide  adaptation  to 
the  chin  and  is  attached 
by  a  bandage  to  the 
back  of  the  neck. 

Metal  Splint.  —  Fig- 
ure 48  {Kingsley) 
shows  a  splint  devised 
by  a  Mr.  Moon,  con- 
sisting of  a  partially 
adapted  metal  splint 
which  is  attached  to  the 
teeth  by  means  of  wires 
passed  through  holes  in 
it  and  around  the  neck 
of  the  tooth. 

In  Figures  49  and  50 


Fig. 


il. — Hayward  Splint. 
(Kingsley.) 


170    MAXILLAEY  FRACTURES  (MECHANICAL) 

(Kingsley)    is   shown   a   modification  of  this  device,  in 
which   there   is  a   metal  chin   piece  used,  there  being  a 

flanged  portion  of  the  chin 
piece  in  the  upper  and  lower 
part  through  which  holts  are 
passed  held  in  place  by  nuts 
beneath  the  flanges.  This  chin 
piece  was  held  in  place  by  a 
strap  passing  from  it  around 
the  back  of  the  neck  and  an- 
other one  over  the  top  of  the  head.  This,  as  you  may 
observe,  provides  a  little  more  substantial  apparatus 
t  h  a  n  the  previous 
one. 


Hayward  Splint.— 
F  i  (j  u  r  e  51  {Kings- 
ley)  is  known  as  the 
Hayward  splint  and 
is  in  a  way  a  modifi- 
cation of  the  Moon 
splint,  b  e  i  n  g  also 
made  of  metal,  but  more  accurately  adapted  or  swaged 
to  fit  the  teeth.  It  is  provided  with  metal  arms  soldered 
to  the  upper  portion  of  the  splint  and  so  formed  as  to 


Fig.      52. — Bullock  's      Modification      of 
Hayward  Splint.      (Kingsley.) 


Fig.  53. — Kingsley  Splint.     (Kingsley.) 

project  out  on  each  side  of  the  mouth  for  the  purpose  of 
carrying  the  bandage  from  one  to  the  other  beneath  the 
chin.    This  splint  was  planned  in  1858  by  Mr.  Hayward 


Fig.  54. — I  nterdental 
Splint  (Gunning)  . 
(Kingsley.) 


TREATMENT  OF  MAXILLARY  FRACTURES     171 

of  London  and  is  usually  considered  the  first  actually 
fitted  splint  which  was  ever  devised. 

Adaptations. — The  next  splint,  Figure  52  {Kingsley), 
devised  by  Dr.  Bullock  of  Savan- 
nah, Georgia,  was  made  very  sim- 
ilar to  the  Hayward  splint  ex- 
cept that  it  was  vulcanite  in  place 
of  metal.  Arms  were  used  sim- 
ilar to  those  of  the  Hayward 
splint  and  it  was  maintained  in 
conjunction  with  a  wood  chin 
piece,  which  was  attached,  not  by 
a  bandage,  but  by  stout  cords. 

Figure  53  {Kingsley)  is  a  fur- 
ther modification  or  adaptation  of  this  same  principle. 
It  is  known  as  the  Kingsley  splint,  which  is  usually  con- 
sidered the  forerunner  of  the  modern  vulcanite  splint, 

and  is  made  with  arms  or 
without,  either  rigidly  at- 
tached or  detachable.  These 
three  splints,  the  Hayward, 
Bullock  and  Kingsley,  form 
a  distinct  series  in  the  de- 
velopment of  the  "fitted" 
splint. 

Interdental  Splint.  —  The 
foregoing  may  in  a  meas- 
ure terminate  what  may  be 
classed  as  the  history  of  ap- 
pliances, for,  from  this  time 
on,  practically  all  of  the  ap- 
pliances were  modifications 
of  these  already  referred  to. 
The  first  of  these  modifica- 
tions is  called  the  interdental  splint.  It  was  constructed 
by  Dr.  Gunning  of  New  York  in  1861,  and  it  practically 
consists  of  two  splints  placed  over  the  teeth  of  each  jaw 


Fig.  55. — Interdental  Splint 
Used  in  Confederate  Army. 
(Kingsley.) 


172     MAXILLARY  FRACTURES  (MECHANICAL) 


with  a  space  provided  for  the  passage  of  nourishment. 
Figures  54  and  55   (Kingsley)   represent  an  appliance 

of  this  nature  and 


show  an  interden- 
tal splint  in  place 
on  the  teeth,  a 
wood  chin  piece 
and  a  strap  band- 
age being  applied 
on  t  h  e  outside. 
This  was  consid- 
erably used  by 
Dr.  Bean  of  At- 
lanta in  1864  in 
cases  of  fractured 
jaws  occurring  in 
the  Confederate 
army. 

Figure  56 
(Kingsley)  repre- 
sents an  interdental  splint  (a  modification  of  the  one  pre- 
viously referred  to),  by  Dr.  Harrison  Allen,  attached  by 
means  of  screws  or 
bolts  passed 
through  the  inter- 
dental spaces.  This 
particular  splint 
referred  to  was  de- 
vised for  use  on  an 
insane  patient  with 
whom  all  ordinar- 
ily used  appliances 
were  unsuccessful 
because  he  pro- 
ceeded   to    remove 

them  when  left  alone.     This,  however,  proved  to  be  a 
permanent  attachment   and   has  many   applications   to 


Fig. 


56. — Interdental  Splint    (Allen). 
(Kingsley.) 


Fig.  57. — Modified  Moon  Splint.     (Kingsley.) 


TREATMENT  OF  MAXILLARY  FRACTURES     173 


cases  other  than  those  of  insane  persons,  for  in  many 
instances  it  is  difficult  to  retain  these  splints  in  posi- 
tion. 

Figure  57  (Kingsley)  represents  a  modification  of  the 
original  Moon  splint,  which  was  partially  attached  to  the 
teeth  by  means  of  wires. 

Crib  Splint. — Figure  58  {Kingsley)  represents  a  splint 
which  would  be  suitable  for  a  fracture  of  the  superior 
maxilla,  this  par- 
ticular one  being  es- 
pecially adapted  to 
cases  w  here  the 
process  is  so  frac- 
tured that  the  teeth 
project  outwardly 
from  their  original 
position,  necessitat- 
ing the  use  of  either 
ligatures  or  rubber 
bands  around  the 
hooks  to  draw  them 

back  into  position.  This  splint  should  more  accurately 
be  termed  a  crib  splint,  because  it  does  not  cover  the 
occlusal  surface  of  the  teeth  or  the  hard  palate.  In  sev- 
eral other  fractures  of  the  jaw,  especially  those  where 
the  bones  of  the  jaw  are  separated  from  the  other  bones 
of  the  face,  the  jaw  tends  to  drop  downward;  the  jacket 
splint  covering  the  occlusal  surface  of  the  teeth  and  the 
hard  palate,  with  arms  similar  to  the  Kingsley  splint, 
is  here  used  so  that  a  bandage  or  rubber  band  might  be 
passed  over  the  top  of  the  head  and  carry  the  splint 
with  the  jaw  up  to  its  original  position. 

Another  type  is  the  Kingsley  splint  constructed  with 
detachable  arms,  the  attachment  being  made  by  means  of 
rectangular  metallic  boxes  inserted  in  the  splint  in  the 
region  of  the  bicuspids  and  first  molars.  These  boxes  are 
either  soldered  to  the  splint,  or  are  attached  during  the 


Fig.  58. — Crib  Splint.       (Kingsley.) 


174    MAXILLARY  FRACTURES  (MECHANICAL) 

process  of  vulcanizing,  by  being  embedded  in  the  vul- 
canite and  held  in  place  by  temporary  bars. 


FORMS   OF   FRACTURES 


Some  cases  illustrating  the  forms  and  shapes  of  frac- 
tures will  now  be  considered,  and  also  their  displacement, 
in  order  to  better  determine  the  purpose  of  splints  and 

appliances  and  the  particu- 
lar service  which  they  arc 
intended  to  perform. 

Multiple  Fractures.  —It 
is  only  by  means  of  study- 
ing the  forms  of  the  frac- 
ture and  the  displacements 
so  occasioned  that  it  is  pos- 
sible to  devise  appliances 
for  their  correction  and  re- 
tention. In  Figure  59  {Kingsley)  is  shown  a  lower  jaw 
fractured  in  four  places,  the  condyloid  processes  on  both 
sides  and  the  coronoid  process  on  one  side  being  in- 


Fig.   59. — Multiple   Fracture. 
(Kingsley.) 


Fig.  60.— Separated  Double  Fragment.     (Kingsley.) 

volved  as  well  as  the  body  at  the  median 'line.  In  this 
instance  of  course  it  is  impossible  to  attach  an  appliance 
of  any  description  to  any  of  these  fractures  excepting 


FORMS  OF  FRACTURES 


175 


Fig.  61. — Deformity  After  Necrosis.  (Kingsley.) 

the  one  at  the  median  line,  the  others  being  reduced  and 
held  in  position  by  holding  the  jaw  in  occlusion. 

Figure  60  (Kingsley)  repre- 
sents another  case  where  a  dou- 
ble fragment  from  the  cuspid  to 
the  second  molar  separated  from 
the  rest  of  the  bone  and  moved 
bodily  inward  toward  the  tongue. 
This  case  entails  such  an  appli- 
ance as  will  make  it  possible  to 
hold  this  displaced  fragment  in 
position  and  approximate  the 
ends  of  the  fractured  bone. 

In  Figure  61  (taken  from 
Kingsley)  is  shown  a  case  of  ne- 
crosis and  deformity  resulting 
from  such  a  multiple  fracture. 
The  portion  of  the  jaw  between 
the  cuspid  teeth  has  been  entirely 
lost,  the  muscles  have  drawn  the 


(a)   Front  View. 


(b)   Side  View. 


Fig.     62. — Ununited     Gun- 

fragments  of  the  mandible  closely    shot  Injury.     (Kingsley.) 


176    MAXILLARY  FRACTURES  (MECHANICAL) 

together,    thus   forming   a   very    sharp  V-shaped   arch. 

In  Figure  62  a  and  b   {Kingsley)   is  shown  another 

type  of  deformity  resulting  from  a  fracture,  and  one  for 

which  it  was  necessary  to  devise  a  special  appliance. 


Fig.  63. — Split  Jacket  Plate  with  Jack-Screw.     (Kingsley.) 

This  was  a  case  of  an  ununited  gun-shot  injury  and  neces- 
sitated the  construction  of  a  split  jacket-plate  and  a  jack- 
screw  to  force  the  ununited  fragments  sufficiently  apart 
to  permit  of  the  insertion  of  a  bridge  to  retain  the  frag- 
ments in  their  normal  position.  See  Figure  63  {Kings- 
ley). 

Special  Appliances 

A  short  series  of  cases,  with  the  appliances  which 
have  been  specially  devised  for  their  correction,  will  now 
be  considered. 

Fracture  with  Displacement  of  Fragments.— Figure 
64  {Kingsley)  is  a  case  of  triple  fracture,  one  fracture 
on  the  right  side  between  the  cuspid  and  the  lateral,  a 
similar  location  on  the  left  side  and  between  the  first 
and  second  molars  on  the  left.  This  case  shows  a  typical 
displacement  of  fractures  near  the  angle.  It  is  important 
to  bear  this  displacement  well  in  mind  and  not  to  be  mis- 
led by  its  appearance.  In  many  instances  of  this  dis- 
placement the  patient,  not  realizing  his  difficulty,  has  ap- 
plied to  a  dentist  for  relief,  the  tooth  being  longer  than 
it  should  be.  The  tooth  in  this  case  was  the  second  molar 
and  its  frasmient  was  in  normal  occlusion:  but  the  dis- 


FORMS  OF  FRACTURES 


177 


placed  fragment  being  lower  than  this,  gave  the  tooth 
the  appearance  of  being  too  long.  In  certain  instances 
it  has  been  extracted  for  no  other  reason  than  the  in- 
ability  of  the   patient   to 


bring  the   displaced   por- 
tion into  occlusion.    This, 
of  course,  is  an  absolutely 
erroneous     diagnosis,     as 
the  fragment  or  displaced 
segment  is  the  one  which 
should  be  brought  up  into 
occlusion  by  being  raised 
in  relation  to  the  other  or 
stationary  fragment.     In- 
stances in  which  this  tooth  has  been  extracted  or  where, 
owing  to  its  extreme  looseness,  it  is  necessary  to   ex- 
tract it,  complicate  the  treatment  of  the  case  to  a  con- 
siderable  extent,  it  being  then  necessary  to   construct 


Fig.   64. — Triple   Fracture. 
(Kingslcy.) 


Fig.    65. — Vulcanite   Plate    with    Arms.      (Kingslcy.) 


an  extension  on  the  splint  or  such  other  appliance  as  may 
be  used.  This  extension  will  impinge  on  the  bone  of  the 
ramus  portion  and  hold  it  down  in  the  same  position  that 


17S     MAXILLARY  FRACTURES  (MECHANICAL) 

the  teeth  held  it  in  normally.  This  particular  case  was 
treated  by  means  of  a  vulcanite  plate  with  arms,  the  typi- 
cal Kingsley  splint, 
which  is  shown  in  Fig- 
ure 65  (Kingsley). 

Figure  66  [Kings- 
ley)  shows  another 
case  of  triple  fracture. 
In  this  instance  the 
fragment  which  was 
displaced  between  the 
other  stationary  por- 
tions of  the  jaw  was 
relatively  small,  al- 
thought  containing 
four  teeth.  It  was  entirely  loosened  and  separated  from 
the  bone  to  such  an  extent  that  it  was  later  removed  as 


Fig.     6(5. — Fractured     Fragment     with 
Four  Teeth.     (Kingsley.) 


Fig.  6; 


-Models  op  Displacements  and  Splints  Used  for  Fixation. 
(Kingsley.) 


TYPES  OF  APPLIANCES  179 

a  sequestrum.  The  Kingsley  splint  and  arms  with  band- 
age and  chin  piece  were  used  in  this  case.  In  Figure  67 
(taken  from  Kingsley)  are  illustrations  from  two  cases 
showing  models  of  the  displacement  and  the  splints  used 
for  fixation. 

TYPES  OF  APPLIANCES 

The  appliances  suitable  for  the  treatment  of  maxillary 
fractures  may  be  classed  under  three  heads :  first,  splints; 
second,  bands  and  ligatures;  third,  bandages  and  chin 
pieces  or  other  combination. 

Fixation.— The  purpose  of  the  appliance  in  the  treat- 
ment of  a  maxillary  fracture  is  the  reduction  of  the  dis- 
placement and  the  fixation  of  the  parts.  It  is  impossible 
to  overemphasize  the  importance  of  fixation.  And  it 
must  be  just  as  nearly  absolute  as  it  is  possible  to  ob- 
tain. If  the  fixation  is  not  definite,  the  fracture  will 
not  readily  unite.  Therefore,  every  modification  and 
every  appliance  should  be  devised  and  applied  in  order 
to  produce  this  absolute  fixation  of  the  fragments  of  a 
fractured  jaw.  The  difficulty  in  applying  this  principle 
to  a  lower  jaw  is  very  great,  more  than  to  any  other 
bone  in  the  body,  on  account  of  its  shape,  the  attachment 
of  the  muscles  and  the  function  of  those  muscles  so 
closely  allied  with  the  functions  of  life  itself.  Every 
breath  one  draws,  every  time  one  swallows,  there  is  a  con- 
traction of  the  muscles  attached  to  this  bone,  and  it  is 
with  the  utmost  difficulty  that  fixation  is  accomplished. 
None  of  these  difficulties  is  present  to  any  great  extent 
in  cases  of  fracture  of  the  upper  jaw.  As  there  is  an 
almost  entire  absence  of  muscular  attachment,  there  is  no 
movement  as  with  the  lower  jaw.  In  treating  fractures, 
especially  fractures  occurring  on  the  battle  field,  prompt 
attention  is  essential,  and  it  is  extremely  necessary  and 
desirable  to  prevent,  as  far  as  possible,  functional  dis- 
turbance and  deformity.     It  should  be  the  purpose  in 


180    MAXILLARY  FRACTURES   (MECHANICAL) 

treatment  of  such  cases  to  apply  such  simple  apparatus 
as  may  be  put  in  place  quickly  and  will  permit  of  the 
cleansing  of  the  wound  and  reestablishment  of  the  func- 
tion of  the  parts. 

Fractures  of  recent  origin  are  very  easily  and  quickly 
reduced  ordinarily  and  may  be  done  at  once.  Cases  of 
long  standing,  of  delayed  attention,  usually  have  to  be 
reduced  by  a  slower  process, — by  such  long  continued 
pressure  as  is  produced  by  orthopedic  appliances. 

Temporary  Treatment.— In  treating  cases  for  trans- 
portation from  the  field  or  any  case  which  can  be  given 
only  temporary  attention,  it  is  important  to  bear  in 
mind  the  possibility  of  causing  more  displacement  than 
originally  occurred  by  means  of  bandages  or  other  appli- 
ances. This  is  especially  true  where  nothing  but  the 
bandage  is  applied  and  where  the  form  of  the  fracture 
itself  is  such  as  to  permit  the  ends  of  the  bone  to  slip 
past  each  other  and  to  be  pressed  together  by  the  tight 
bandage.  If  the  fracture  is  square  and  the  ends  of  the 
bone  impinge  directly  upon  each  other,  considerable  pres- 
sure may  be  applied  without  danger  of  causing  displace- 
ment, but  with  a  diagonal  shaped  fracture  even  a  slight 
pressure,  lasting  over  a  period  of  a  day  or  two,  will 
cause  such  displacement  as  later  may  give  considerable 
trouble,  pain  and  delay  in  reduction.  In  cases  of  this 
kind  it  is  far  better  to  wire  the  lower  jaw  directly  to  the 
upper,  which  will  give  support  and  prevent  such  dis- 
placement taking  place. 

Splints 

Various  Types.— There  are  several  kinds  of  splints: 
first  the  jacket  splint,  which  may  be  an  upper  or  a  lower, 
and  may  be  constructed  of  vulcanite  or  metal.  The 
metal  may  be  swaged  or  cast,  and  there  may  or  may  not 
be  arms  employed. 

Next  is  the  interdental  splint,  which  is  a  double  jacket 


TYPES  OF  APPLIANCES  181 

splint,  covering-  the  teeth  of  both  jaws,  adapted  to  form 
one  splint  but  with  spaces  for  the  passage  of  nourish- 
ment provided  by  opening  the  bite  slightly. 

Third  the  edentulous  splint,  which  is  an  interdental  or, 
more  properly,  inter  edentulous  splint  for  the  edentulous 
cases. 

Difficulties  of  Splints.  — Splints  are  adapted  to  a  certain 
class  of  cases,  it  being  almost  impossible  to  treat  some 
cases  without  their  use.  But  the  use  of  splints  entails 
certain  very  definite  difficulties.  In  the  first  place,  con- 
siderable time  must  be  consumed  in  their  construction, 
probably  at  the  best  a  matter  of  six  or  eight  hours,  while 
frequently  this  time  is  extended  to  as  many  days.  In 
addition  to  this  delay,  it  is  a  difficult  matter  to  construct 
a  splint.  A  series  of  correct  mechanical  steps  is  re- 
quired, the  failure  or  imperfection  of  any  of  which  means 
that  all  that  follow  will  be  inaccurate.  This  is  similar 
to  the  difficulty  in  the  construction  of  artificial  dentures 
and  may  be  likened  to  the  building  of  a  stone  wall,  in 
which  the  failure  to  place  any  one  stone  correctly  inter- 
feres with  the  ultimate  strength  and  accuracy  of  the 
remaining  portion.  This  is  the  reason  that  dental  stu- 
dents and  practitioners  have  so  much  difficulty  with  me- 
chanical dentistry;  each  step  must  be  absolutely  correct 
in  order  to  have  the  completed  apparatus  correct. 

There  are  certain  things  essential  in  the  construction 
of  the  splint,  the  first  being  the  impression. 

Taking  of  Impressions 

Plaster  Impressions.— The  impression  should  be  taken 
in  plaster,  either  in  one  piece,  if  there  is  not  much  dis- 
placement, or  in  sections  if  there  is  considerable  displace- 
ment. It  is  ordinarily  not  desirable  to  make  any  attempt 
to  reduce  the  fracture  until  after  the  splint  has  been 
made.  Plaster  is  selected,  first,  because  it  is  easier  for 
the  patient,  no  pressure  being  required;  and  secondly, 


182    MAXILLARY  FRACTURES   (MECHANICAL) 

because  it  gives  accurate  results.  And  in  no  class  of 
work  is  it  more  necessary  to  obtain  an  accurate  impres- 
sion and  an  accurate  model  than  in  the  construction  of 
the  splint.     In  case  the  patient  is  unable  to  open  the 


Fig.  68. — Plaster  Model,  Cut  at  Line  of  Fracture. 

mouth  sufficiently  to  admit  of  the  introduction  of  an  im- 
pression tray,  the  plaster  may  be  carried  into  the  mouth 
by  means  of  a  spatula  and  then  worked  around  the  teeth 
and  a  tray  forced  in  after  it,  the  rim  of  the  tray  having 
been  previously  nearly  cut  away. 


Fig.  69. — Ee-posed  Plaster  Model,  Impression. 

Perfection  of  Model  Essential. — The  second  require- 
ment is  a  perfect  model.  This  model  must  not  be  injured 
in  its  removal  from  the  impression;  there  must  not  be  a 
chip  lost  from  it,  not  a  corner  of  a  tooth  missing.     It 


TYPES  OF  APPLIANCES  183 

should  be  in  hard  plaster  and  should  be  treated  with  the 
greatest  respect,  as  upon  it,  providing  the  impression 
has  been  accurate,  depends  the  success  of  all  succeeding 
steps.  If  the  impression  was  taken  in  one  piece  the 
model  must  be  cut  apart  at  the  line  of  the  fracture  (see 
Figure  68),  the  ends  trimmed  and  brought  together  so 
that  the  teeth  may  be  articulated  with  those  of  the  oppo- 
site jaw,  which,  by  means  of  the  cusps  and  facets,  may  be 
very  accurately  done.    If,  on  the  other  hand,  the  impres- 


Fig.  70. — Upper  Model  Attached  to  Articulator. 

sion  was  taken  in  sections,  this  reconstruction  or  re-pos- 
ing of  the  model  can  be  accomplished  just  as  readily,  the 
only  difference  being  that  there  is  no  necessity  for  cutting 
the  model  in  two.  After  the  model  has  been  accurately 
re-posed  {see  Figure  69),  it  should  be  held  in  this  posi- 
tion by  means  of  temporary  attachments  of  wax  and 
splints  of  wood  and  new  plaster  added  in  order  to  make 
the  two  parts  into  one  piece  again. 

Articulation.— After  this  has  been  accomplished  it  is 
necessary  that  the  opposite  model — ordinarily  the  upper 
one — should  be  set  on  the  anatomical  articulator  by  the 
use  of  a  face  bow  (see  Figure  70).  This  is  essential  on 
account  of  the  fact  that  in  the  construction  of  the  splint 
the  bite  must  be  opened,  and  the  bite  cannot  be  opened  on 
a  plane-line  articulator  or  without  the  use  of  a  face  bow, 


L84    MAXILLARY   FRACTURES   (MECHANICAL) 


except  by  disturbing  the  relationship  of  this  bite.     The 
face  bow  gives  the  relation  of  the  model  to  the  coin  Ivies  of 


Fig.  71. — Re-posed  Lower  Model  Set  on  Anatomical  Articulator. 

the  articulator,  between  the  teeth  and  the  condyles  as  it  is 
in  the  patient,  and  locates  the  model  on  the  articulator, 


Fig.   72. — Simple  Vulcanite  Jacket  Splint. 

not  only  with  the  exact  distance  from  the  condyles  to  the 
cutting  edges  of  the  incisor  teeth,  but  also  locates  it  in 


TYPES  OF  APPLIANCES  185 

reference  to  the  horizontal  and  to  the  vertical  positions. 
In  other  words,  it  locates  it  in  three  dimensions  so  that 
the  bite  may  be  opened  and  the  splint  adjusted.  When 
that  splint  is  placed  in  the  mouth  of  the  patient  the  teeth 
will  fit  into  the  splint  just  as  they  did  on  the  model  on 
the  articulator;  otherwise,  there  is  great  likelihood,  al- 
most certainty,  of  a  misfit  so  far  as  the  bite  is  concerned ; 


Fig.  73. — Vulcanite  Splint  with  Arms  for  Bandaging. 

the  molar  teeth  impinging  on  the  splint  in  their  proper 
relation  but  the  incisor  teeth  failing  to  come  in  contact 
with  the  splint. 

Figure  71  shows  the  upper  model  attached  to  the  artic- 
ulator and  the  face  bow  removed,  with  the  lower  re-posed 
model  occluded  or  articulated  with  the  upper. 

Packing  the  Mold. — Careful  and  accurate  flasking  and 
packing  of  the  mold,  having  previously  placed  tinfoil 
over  the  teeth  of  the  model,  and  accurate  and  complete 
closing  of  the  flask  after   packing  are  absolute  essen- 


186    MAXILLARY  FRACTURES   (MECHANICAL) 

tials.  Regardless  of  how  accurately  every  step  up  to 
this  point  has  been  followed,  failure  to  close  the  flask 
completely  on  one  side  or  the  other  will  upset  everything 
and  all  previous  accuracy  go  for  naught. 

Occlusion.  — It  is  also  necessary  that  there  should  be 
an  absolutely  square  strike  of  the  opposing  teeth  upon 
the  splint  when  it  is  in  complete  adjustment  in  the 
mouth.  The  molars,  bicuspids  and  cuspids  on  both  sides 
must  all  occlude  on  the  splint,  otherwise  there  will  be  a 
tilting  of  the  splint  and  a  lack  of  fixation. 
Figure  72  shows  a  simple  vulcanite  jacket  splint,  prop- 
erly adjusted  in  position 
with  teeth  occluding  as  de- 
scribed above;  while  Fig- 
ure 73  shows  the  same 
type  of  splint  constructed 
with  arms  for  use  in  ban- 
daging. Figure  74  illus- 
trates a  fitted  metal  splint 
made  to  be  cemented  on  to 
the  teeth. 

Opening  of  the  Bite.— 
In  the  construction  of  the 
interdental  splint,  in  addition  to  the  above  it  is  desirable 
that  the  bite  be  opened  as  little  as  possible,  first  on  ac- 
count of  the  comfort  of  the  patient.  This  may  be  deter- 
mined by  placing  the  joint  of  the  thumb  between  one's 
own  teeth  and  attempting  to  swallow,  then  place  in  the 
opening  the  tip  of  the  little  finger  and  swallow,  and  one 
will  have  no  difficulty  in  determining  which  is  more  com- 
fortable. Further  than  the  reason  of  giving  the  patient 
the  benefit  of  this  additional  comfort,  which  is  in  evidence 
every  time  he  swallows,  is  the  very  evident  one  of  permit- 
ting the  closing  of  the  lips  to  a  sufficient  extent  to  allow 
of  drinking  from  a  glass  or  cup  rather  than  to  have  to 
use  a  feeding-tube.  Another  very  important  reason  for 
this  slight  opening  is  that  there  is  less  displacement  of 


Fig.  7-4. — Fitted  Metal  Splint. 


TYPES  OF  APPLIANCES  187 

the  fragments;  if  the  fracture  is  posterior  to  the  first 
molar  this  displacement  is  considerably  increased  by 
opening  the  bite,  and  should  be  avoided  when  possible. 

Figure  75  illustrates  the  features  referred  to  above 
and  shows  a  double  jacket  or  interdental  vulcanite  splint. 

A  splint  is  not  particularly  applicable  to  fractures  oc- 


Fig.  75. — Interdental  Vulcanite  Splint. 

curring  in  regions  posterior  to  the  first  molar,  there  not 
being  a  sufficient  number  of  teeth  or  a  sufficient  amount 
of  surface  contact  with  the  splint  to  enable  it  to  hold 
the  parts  in  fixation.  But  for  fractures  anterior  to  the 
first  molar,  splints  may  be  used  if  desired ;  they  may  be 
interdental,  they  may  be  a  simple  jacket  splint  of  vulcan- 
ite, or  may  be  a  swaged  or  cast  metal  splint  cemented  on 
to  the  tooth. 


188    MAXILLARY  FRACTURES   (MECHANICAL) 


Bands  and  Ligatures 

Application  to  Emergency  Work.— The  great  advan- 
tage of  this  type  of  apparatus  is  the  possibility  of  its 
immediate  application.  Whereas  the  best  time  for  a 
splint  may  be  six  or  eight  hours,  ligatures  may  be  ap- 
plied immediately,  and  in  simple  cases  be  completely 
adjusted  in  six  to  eight  minutes.  This  method  is  very 
useful  for  preparing  cases  for  transportation,  such  as 
emergency  work  on  the  battle  field  or  in  a  field  hospital. 
Ligatures  applied  directly  around  the  necks  of  the  teeth 
are  of  course  much  more  quickly  adapted  than  where 

bands  are  used  and  the  lig- 
atures  attached  to  them. 
The  banding  method,  how- 
ever, is  much  more  elastic 
and,  in  the  instance  of  the 
breaking  of  one  of  the  wire 
ligatures,  entails  less  dif- 
ficulty.     When    ligatures 
are  used  around  the  necks 
of  the  teeth,  if  one  breaks 
it  is  usually  necessary  to  renew  all  of  them,  whereas,  with 
the  employment  of  bands,  one  may  be  renewed  without 
disturbing  the  others. 

Bands.— These  clamped  bands  are  practically  Angle 
orthodontia  bands,  and  may  be  applied  very  quickly,  pro- 
vided there  is  sufficient  space  between  the  teeth.  They 
are  provided  with  tubes,  rings  or  studs  for  the  attach- 
ment of  ligatures  or  arch  wires.  Two  Angle  bands  on 
the  molars,  provided  with  tubes  through  which  an  arch 
wire  may  be  placed,  and  ligatures  applied  around  the 
anterior  teeth,  provide  a  very  quickly  adapted  appliance 
and  one  which  satisfactorily  maintains  a  very  fair  de- 
gree of  fixation  for  transportation  and  which  will  in 
many  cases  answer  all  that  is  desired  for  a  permanent 
appliance.     (It  probably  would  not  be  desirable  for  the 


Fig 


Angle  Orthodontia  Band. 


TYPES  OF  APPLIANCES 


189 


average  man  to  attempt  to  apply  nuts  to  the  distal  ends 

of  the  arches  while  in  an  exposed  position  on  the  field.) 

Angle  Apparatus. — These  appliances  are  usually  known 

as  Angle  No.  1,  2  and  3  apparatus  for  maxillary  frac- 


Fig.  77. — No.  2  Angle  Apparatus. 

tures.  The  No.  1  appliance  shown  in  Figure  76  (Garret- 
son)  is  an  ordinary  expansion  arch  with  bands.  The  No. 
2  appliance,  Figure  77  {Gar  ret  son),  consists  of  bands 
applied  to  teeth  of  both  jaws  attached  nearly  opposite 
to  each  other  and  provided  with  rings  or  studs  for  the 


Fig.  78. — Figure  of  Eight  Ligature. 

attachment  of  ligatures,  or  further  modified  by  means  of 
tubes  and  rings  for  the  attachment  of  L-threaded  rods 
and  nuts.  The  No.  3  appliance  consists  of  patella-hooks 
inserted  in  holes  drilled  in  the  bone  in  edentulous  or  semi- 
edentulous  cases.  Around  these  hooks  wire  ligatures  are 
placed  in  the  form  of  a  figure  8  (Figure  78).    The  writer 


190    MAXILLARY  FRACTURES   (MECHANICAL) 

has  used  to  advantage  a  modification  of  this  appliance, 
utilizing,  in  place  of  the  patella-hooks,  ordinary  silver- 
plated  brass  wood  screws,  three-eighths  of  an  inch  long, 
of  fairly  heavy  diameter.  The  essential  thing  in  the  use 
of  these  screws  is  that  the  drill  be  very  carefully  selected 
as  to  its  size,  which  should  previously  be  ascertained  by 
drilling  a  hole  in  a  piece  of  bone  and  testing  the  screw. 


Fig.  79. — Ligatures  Adjusted  to  Individual  Teeth. 

The  correct  adjustment  as  to  size  is  that  the  drill  be  of 
a  size  to  permit  of  one  half  of  the  thread  of  the  screw 
becoming  embedded  into  the  bone  and  cutting  its  own 
thread.  If  the  hole  is  too  small  the  bone  will  be  crushed 
and  fractured;  if  it  is  too  large  the  screw  will  not  seat 
properly  and  will  not  provide  a  firm  attachment. 

Mode  of  Application.— This  Angle  apparatus  may  be 
used  in  edentulous  cases  by  placing  one  or  two  screws  in 
each  fragment,  or  by  using  the  screws  in  one  fragment 
of  the  semi-edentulous  case  and  attaching  the  ligature  at 
the  other  end  to  a  band  or  modification  of  a  band  at- 


TYPES  OF  APPLIANCES 


191 


tached  to  the  teeth.  The  No.  1  or  No.  2  appliance  is  the 
most  universal  of  any,  it  being  applicable  to  a  fracture 
in  any  location,  whether  in  the  neck  of  the  condyle,  or  in 
the  body  or  in  the  ramus  portion;  the  only  essential  re- 
quirement in  this  case  being  that  there  must  be  a  suffi- 
cient number  of  teeth  present  to  permit  of  the  attach- 
ment of  ligatures  or  bands,  and  a  sufficient  number  of 


Fig.    80. — Ligatures   in    Final   Adjustment. 


teeth  to  provide  a  fairly  interlocking  occlusion  so  that  the 
jaw  may  be  fixed  between  the  stress  of  the  ligatures  and 
the  strike  of  teeth.  (Inasmuch  as  it  is  a  requirement  for 
enlistment  that  a  man  possess  four  teeth,  two  in  each 
jaw,  which  are  opposed  or  occluding,  it  may  be  possible 
to  apply  this  apparatus  to  all  cases  of  fractures  occur- 
ring in  the  army.)  (See  Figures  79  and  80.)  In  apply- 
ing the  ligatures  it  is  essential  that  they  be  so  located  as 
to  draw  the  teeth  more  firmly  into  occlusion  rather  than 
to  draw  them  out  or  to  fail  to  draw  them  in.    Fractures 


192    MAXILLARY  FRACTURES   (MECHANICAL) 

with  much  tendency  to  displacement  should  be  wired 
across  the  seat  of  the  fracture  before  ligating  the  teeth 
of  the  lower  jaw  to  those  of  the  upper,  and  it  is  fre- 
quently desirable  to  cross  the  ligatures  in  order  to  more 
firmly  draw  the  fragments  together.  In  general,  the  liga- 
tures should  be  so  placed  that  absolute  fixation  is  accom- 
plished, not  only  during  the  period  of  rest,  but  during 
the  action  of  swallowing,  as  during  this  time  more  strain 
is  put  upon  the  appliance  than  at  others. 

Bandages  and  Chin-Pieces 

Application. — The  bandage  was  probably  the  first  ap- 
pliance ever  used  for  relief  or  treatment  of  a  broken  jaw, 
it  being  the  first  thing  which  wTould  be  suggested  to  the 
mind  as  a  means  of  support.  Bandages  should  be  ap- 
plied with  due  reference  to  the  location  of  the  frac- 
ture and  should  be  so  adapted  as  to  hold  the  fractured 
ends  together  rather  than  to  cause  them  to  become  sepa- 
rated. A  bandage  applied  at  the  exact  location  of  the 
fracture  may  frequently  permit  the  extended  ends  of 
the  bone  to  sag  and  cause  a  separation  of  the  fragments, 
whereas  if  the  bandage  be  applied  slightly  beyond  the 
actual  fracture  the  anterior  fragment  is  better  supported. 
A  better  way  of  accomplishing  this  is  by  the  use  of  the 
splint  or  chin-piece,  giving  extended  support  to  the  frag- 
ment, the  bandage  serving  merely  to  hold  the  splint  or 
chin-piece  in  position.  Several  forms  of  bandages  have 
been  devised  for  use  in  connection  with  broken  jawrs,  to 
many  of  which  are  applied  the  names  of  their  originators. 
However,  as  with  the  other  appliances,  they  are  very 
similar  and  consist  of  modifications  of  a  few  principles. 
The  simplest  form  of  bandage  is  known  as  the  four-tailed 
bandage,  the  name  being  derived  from  the  shape  of  the 
bandage. 

Four-tailed  Bandage.— This  is  formed  from  a  piece  of 


TYPES  OF  APPLIANCES 


193 


cloth  about  a  yard  long  and  three  to  four  inches  wide, 
merely  cut  in  two  pieces  from  the  ends,  leaving  a  piece 
in  the  center  four  or  five  inches  long,  which  slotted  por- 
tion is  applied  directly  to  the  chin,  the  two  under  ends 
or  tails  of  the  bandage  being  carried  above  the  head  and 
tied  and  the  two  upper  ones  being  carried  around  the 
back  of  the  neck  and  tied,  thus  forming  a  crossed  support 
and  chin-piece  bandage.  The  tied  ends  are  again,  in 
turn,  tied  to  each  other  so  that  the  ends  going  over  the 
top  of  the  head  are  attached  to  those  going  around  the 
back  of  the  neck,  thus  providing  a  firmer  attachment 
than  would  otherwise  be  accom- 
plished. The  best  permanent 
bandage  is  either  the  Barton  or 
a  modification  of  it.  The  four- 
tailed  bandage  is  shown  in  Fig- 
ure 81  (Kingsley) ;  the  Barton 
bandage  and  its  modifications 
a  n  d  chin-pieces  are  also 
shown.  (See  Figure  82,  on 
page  194.) 

Barton  Bandage.  — The  Bar- 
ton-Gibson bandage  is  prefer- 
ably a  gauze  roller,  one  and  a 
half  inches  wide  and  from  ten 
to  fifteen  yards  long.  It  should 
be  applied  rather  more  tightly 

than  is  ordinarily  done  for  head  bandages.  During 
its  application  it  is  essential  that  the  patient's  teeth 
should  be  closed  tightly,  otherwise  the  bandage  will 
be  very  loose  when  the  teeth  are  closed.  This  is  a 
point  that  requires  particular  attention,  for  it  is  a 
great  temptation  to  the  patient  to  place*  the  tip  of  his 
tongue  between  the  teeth  in  order  to  avoid  tight  bandag- 
ing. Of  course  when  the  bandage  is  applied  tightly  care 
should  be  exercised  that  it  does  not  produce  soreness  over 
the  exposed  portions  of  the  lower  jaw,  also  that  it  does 


Fig.  81. — Four-tailed  Bandage. 


194    MAXILLARY  FRACTURES   (MECHANICAL) 

not  encroach  too  much  upon  the  throat,  as  otherwise  seri- 
ous complications  might  arise. 

Chin-pieces.— Chin-pieces  are  made  in  various  forms 
and  of  various  materials : — gutta-percha,  modeling  com- 
pound, binders '-board,  wood,  starched  gauze,  plaster 
mask,  etc.  They  are,  when  properly  constructed  and  ap- 
plied, a  decided  addition  to 
bandages  alone  and  to  ap- 
pliances inside  the  mouth. 

A  very  quickly  and  easily 
made  form  of  chin-piece  is 
cut  from  a  piece  of  binders' 
board. 

It  is  desirable  to  empha- 
size what  was  referred  to 
in  the  beginning,  that  all 
recent  methods  and  appli- 
ances for  the  treatment  of 
maxillary  fractures  are 
merely  repetitions  or  modi- 
fications of  old  methods  as 
far  as  fundamentals  are 
concerned,  but  also  that,  in 
cases  occurring  in  the  recent  war,  these  same  funda- 
mentals have  been  applied  and  practically  no  device 
radically  new  has  been  used.  The  writer  has  gone 
very  carefully  over  the  records  and  photographs  of  a 
large  number  of  cases  which  have  been  treated  in 
France,  and  finds  the  above  to  hold  true  in  every  in- 
stance, as  will  be  seen  by  cases  reported  by  Dr.  Geo. 
B.  Haynes,  "Dental  Cosmos,"  1916.  To  be  sure,  the  cases 
are  more  numerous  than  they  have  ever  been  before, 
and  on  account  of  the  type  of  warfare  in  trenches, 
with  consequent  exposure  of  the  head,  there  has  been 
more  plastic  surgery  and  bone  grafting  necessary  on 
account  of  such  great  loss  of  tissue;  but  the  appliances 
for  the  reduction  and  fixation  of  fractures  and  for  pros- 


82 — Showing     Application 
of  Chin-piece. 


TYPES  OF  APPLIANCES  195 

thesis  to  be  used  as  a  foundation  for  plastic  surgery  have 
been  the  same. 


References 

Kingsley.     Oral  Deformities,  259-408. 
Garretson.     Oral  Surgery,  821-823. 

American  System  of  Dentistry. 
Heath  and  Hamilton.     Fractures  and  Injuries  of  the 
Jaws. 

Hayes.     War  Fractures,  Dental  Cosmos,  1916. 


CHAPTER  VII 

MAXILLARY  FRACTURES  (SURGICAL) 

Albert  L.  Midgley,  D.M.D. 

Scope  of  Chapter.— Some  of  the  information  presented 
in  this  chapter  is  to  be  found  in  the  textbooks  and  the  re- 
mainder is  from  the  writer's  own  experience,  embracing 
the  treatment  of  seven  hundred  and  seventy-eight  frac- 
tures of  the  maxillary  bones.  While  the  treatment  of 
every  case  is  individual  in  itself,  yet,  as  a  whole,  the 
application  is  somewhat  similar.  The  subject  will  be 
dealt  with  as  thoroughly  as  possible  in  the  way  of  theory 
and  treatment,  and  by  treatment  is  meant  surgery  and 
the  surgical  application  of  splints.  For  reading  and 
study  of  this  subject  Brophy's  "Surgery  of  Fractures"  is 
recommended  and  also  the  March,  1917,  issue  of  the 
Journal  of  the  Allied  Societies,  which  contains  an  article 
by  Dr.  Kazanjian,  who,  as  is  generally  known,  is  doing 
wonderful  work  in  Base  Hospital  No.  20,  in  France. 
Some  of  the  statements  in  this  chapter,  particularly  in 
regard  to  gunshot  wounds,  are  taken  from  his  works  and 
also  from  the  articles  on  fractures  appearing  in  the  vari- 
ous dental  journals  since  the  war  began. 

FRACTURES  OF  UPPER  JAW 

Fractures  of  the  upper  jaw  are  considered  first.  They 
may  be  complete  and  incomplete.  There  may  be  a  frac- 
ture of  both  maxillae  or  a  fracture  of  but  one.  A  com- 
plete fracture  may  involve  the  nasal  process,  the  anterior 

196 


FRACTURES  OF  UPPER  JAW  197 

or  posterior  wall  of  the  antrum  and  the  alveolar  and 
palatal  processes.  By  incomplete  fractures  are  meant 
partial  ones  which  may  not  extend  entirely  through  any 
one  process  or  piece  of  bone. 

Types  of  Fractures.— To  simplify  matters  it  may  be 
stated  that  fractures  may  be  classified  as  simple:  that 
is,  when  there  is  no  wound  leading  from  the  fracture 
through  the  mucous  membrane  or  the  external  tegu- 
ment; compound:  when  there  is  such  a  wound;  multiple: 
when  there  is  more  than  one  fracture;  comminuted:  when 
the  bone  is  crushed;  complicated:  when  it  involves  injury 
to  nerves  or  arteries,  or  when  it  is  accompanied  with 
dislocation,  or  some  serious  condition  such  as  pneumonia, 
or,  in  the  case  of  vessels,  the  laceration  of  the  vessels 
and  nerves  with  accompanying  bleeding  and  partial  par- 
alysis; impacted:  where  a  piece  of  the  bone  is  driven 
into  another  piece;  and  the  greenstick,  where  the  frac- 
ture is  incomplete. 

Anatomy  of  Maxillae.— The  maxillae  are  protected  be- 
low by  the  mandible;  above  by  the  frontal  and  malar 
bones;  anteriorly  by  the  nasal  bones;  and  laterally  by 
the  malar  bones,  the  heavy  masseter,  buccinator  and  or- 
bicularis oris  muscles.  It  can  be  seen  from  its  anatomical 
position  and  protection  that  it  is  not  so  liable  to  receive 
the  direct  force  of  violence  as  is  a  fracture  of  the  man- 
dible, that  is  in  speaking  of  fractures  that  occur  in  civil 
life. 

Symptoms.— In  fractures  of  the  maxillary  bones  the 
principal  subjective  symptoms  are  pain  and  tenderness; 
the  objective  symptoms  are  contusions,  lacerations,  dis- 
colorations,  and  drooling,  which  latter  condition  occurs 
with  every  fracture  and  is  a  state  with  which  one  has 
always  to  contend.  The  reason  for  this  is  because  it  not 
only  serves  as  an  irritant  to  the  integument,  but  also 
because  it  is  an  ideal  medium  for  the  growth  of  the 
products  of  decomposition  that  may  be  lying  in  the 
mouth,  inviting  them  to  go  into  the  line  of  fracture; 


198     MAXILLARY  FRACTURES  (SURGICAL) 

thus  producing  an  infection  which  prolongs  the  stage  of 
the  illness  and  prevents  callous  formation  with  the  sub- 
sequent calcification  of  bone.  Crepitus  is  also  present. 
In  examining  fractures  of  the  superior  maxillary  bone, 
it  is  essential  to  remember  that  it  is  not  always  wise  to 
elicit  crepitus,  particularly  in  fractures  that  are  simple 
and  ones  in  which  the  fracture  is  partial.  This  is  im- 
portant in  fractures  of  the  palatal  process  because  the 
vault  of  the  palate  has  a  direct  relation  to  the  brain,  and 
an  infection  may  go  through  the  line  of  fracture  to  the 
meninges  of  the  brain,  producing  meningitis  with  possi- 
bly fatal,  if  not  serious  consequences.  Then  too  it  is 
not  good  surgery  to  needlessly  stir  up  a  bacterial  breed- 
ing pool.  Therefore,  the  point  to  be  borne  in  mind  in 
a  discussion  of  upper  jaw  fractures,  if  they  are  of  the 
palatal  process,  is  not  to  do  too  much  palpation  to  elicit 
crepitus.  The  possibility  of  antral  involvement  in  this 
connection  is  also  obvious. 

Diagnostic  Signs  in  Superior  Maxillary  Fractures.— 
Many  fractures  of  the  superior  maxilla  and  fractures 
of  the  neck  of  the  condyle  of  the  mandible  are  followed 
or  accompanied  by  fractures  at  the  base  of  the  skull.  As 
a  rule,  in  every  fracture  of  the  upper  jaw  there  is  bleed- 
ing through  the  nostrils.  In  many  fractures  at  the  base 
of  the  skull  there  is  bleeding  through  the  nostrils  and 
from  the  ears.  Therefore,  differentiation  should  be  made 
between  these  two  conditions  in  making  a  diagnosis, 
which  of  course  is  a  simple  matter  in  most  instances  in 
fractures  of  the  jaw.  It  is  well  to  remember  that  prac- 
tically every  fracture  of  the  superior  maxillary  bone  is 
accompanied  with  bleeding  from  the  nose.  Sometimes 
this  bleeding  may  be  quite  severe,  particularly  if  it  in- 
volves the  internal  maxillary  artery,  and  in  some  of 
these  cases  fatal  results  have  followed  because  of  the 
fact  that  the  hemorrhage  of  the  internal  maxillary  ar- 
tery could  not  be  controlled. 


FRACTURES  OF  UPPER  JAW  199 

Infection 

Tetanus.— It  is  hardly  necessary  here  to  take  np  the 
pathology  of  tetanus  but  on  account  of  the  possibility 
of  this  occurring  as  a  result  of  gun-shot  wounds,  etc.,  a 
study  of  the  text-books  upomthis  subject  is  recommended. 
It  is  well  to  remember  that  the  latent  type  of  the  disease 
sometimes  appears  and  that  both  dental  irritation  and 
temporary  mandibular  irritation  should  not  be  confused 
with  it.  Quite  frequently  in  fractures  of  the  mandible 
there  is  a  trismus  from  the  induration  in  the  masseter 
region,  and  this  occurs  most  frequently  in  cases  at  the 
angle  or  above  that  point  and  the  joint. 

Points  of  Involvement.— The  involvements  of  fractures 
of  the  superior  maxillary  bone  are  the  maxillary  sinus, 
frontal  sinus,  the  ethmoid,  sphenoid,  nasal  and  the  malar 
bones.  The  infection  resulting  from  fractures  often  in- 
volves the  maxillary  sinus  and  it  is  quite  necessary  for 
the  dentist  in  many  cases  to  enter  this  sinus  to  relieve 
the  pus  that  is  constantly  accumulating.  In  fact,  outside 
of  respiratory  diseases  and  the  general  lowered  resist- 
ance that  often  accompanies  fractures,  there  is  nothing 
to  fear  except  infection  with  necrosis  of  bone,  and  this 
infection  is,  of  course,  more  prone  in  tubercular  and 
specific  cases. 

Causes  of  Pus  Formation.— The  chief  reasons  which 
cause  these  infectious  conditions  to  abound  in  fractures 
are  uncleanliness  and  the  presence  of  a  foreign  body. 
Of  course,  for  the  army  dentist  foreign  bodies  will  be 
either  bullets,  shrapnel  and  so  forth,  or  spicules  of  bone, 
and  these  are  usually  the  cause  of  pus  formation.  In  the 
Avriter's  experience  there  has  not  been  one  case,  where 
all  the  spicules  of  bone  have  been  removed,  in  which 
there  has  not  been  an  absence  of  flow  of  pus  at  least  with- 
in two  days  later,  and  in  most  instances  one  day  later. 
Therefore  the  important  point  is  to  get  the  spicules  of 
bone  that  have  no  live  connection  removed  from  the  site 


200    MAXILLARY  FEACTUEES  (SURGICAL) 

of  fracture,  if  the  flow  of  pus  is  to  be  stopped.  It  will 
never  stop  as  long  as  those  spicules  of  bone  are  there. 
When  a  fracture  is  treated  for  six  or  seven  months,  the 
patient  having  fistulous  openings  on  the  face  with  pus 
flow  not  checked,  it  is  certain  that  there  are  spicules  of 


Fig.  83. — Fracture  Between  Lower  Eight  Cuspid  and  First  Bicuspid. 
Showing  the  importance  of  an  extra  oral  radiograph,  as  the  unerupted 
third  molar  may  be  an  irritant.  A  indicates  spicule  of  bone  in  the  line 
of  fracture;  B  indicates  partially  erupted  inferior  third  molar;  C  indi- 
cates line  of  fracture. 


bone  in  there  or  that  necrosis  is  present.  Examination 
of  various  radiographs,  etc,  strengthens  the  opinion  that 
there  is  no  justifiable  reason  for  letting  them  remain 
there.  Incidentally  there  is  perhaps  no  better  instru- 
ment for  removing  these  pieces  of  bone  than  the  pyor- 
rheal  planers  and  scalers  that  are  used  for  the  removal 
of  tartar,  such  as  are  employed  in  prophylactic  work. 


FRACTURES  OF  UPPER  JAW  201 

These  instruments  may  be  used  for  this  purpose  since 
they  are  readily  adapted  to  any  surfaces  of  the  teeth  and 
may  be  equally  well  applied  to  any  surface  of  the  bone 
where  there  has  been  a  fracture. 

Value  of  Radiographs.— Sometimes  the  radiograph 
may  not  show  that  there  is  a  spicule  of  bone.  The  op- 
erator should  then  have  two  or  three  more  radiographs 


M  X 

Bl  % 

■l 

Fig.  84. — Fracture  at  the  Neck  of  the  Condyle  and  in  the  Body  of 
the  Mandible.  [Showing  the  necessity  for  both  intra-  and  extra-oral 
radiographs. 

taken  at  various  angles  because  in  some  instances,  at  a 
certain  angle,  it  is  impossible  to  detect  a  small  spicule  of 
bone  and  such  a  fragment  may  be  the  cause  of  a  persist- 
ent flow  of  pus.  Every  dentist  has  had  radiographs  made 
when  he  is  searching  for  the  cause  of  an  obscure,  per- 
sistent neuralgia  and  all  know  how  difficult  it  is  to  de- 
termine that  hypercementosis  exists  or  is  the  cause  of 
this  pain.  One  knows  also  that  a  slight  hypercementosis 
may  be  the  cause  of  a  very  severe  neuralgia  and  that  this 
may  not  be  perceptible  in  the  radiograph,  especially  if 
taken  at  only  one  angle.    If,  however,  a  number  of  radio- 


202     MAXILLARY  FRACTURES  (SURGICAL) 

graphs  have  been  made  at  various  angles  it  is  quite  a 
simple  matter  to  detect  a  slight  hypercementosis,  and  this 
may  be  causing-  severe  symptoms.  This  is  perhaps  a  little 
foreign  to  the  subject,  but  has  a  practical  bearing  upon 
the  practice  of  dentistry  and  oral  surgery.  Then  too  it 
emphasizes  the  importance  of  a  series  of  radiographs  in 
searching  for  the  cause  of  the  flow  of  pus. 

Dead  Pulps. — Another  point  to  remember  in  this  con- 
nection is  the  fact  that  the  pulps  of  teeth  may  have  died 
as  the  result  of  the  impact,  and  these  dead  pulps  are  a 
prolific  source  of  irritation  and  incubators  for  pus  for- 
mation that  may  be  present  in  the  line  of  fracture.  The 
tooth  may  have  a  very  good  color  and  to  all  outward 
appearances  seem  to  be  alive  and  yet  the  pulp  may  be 
dead,  and,  with  the  resulting  pus  formation,  feed  the  line 
of  fracture.  Therefore,  if  a  dentist  makes  up  his  mind 
when  treating  a  case  that  a  spicule  of  bone  or  some  for- 
eign body  is  there,  or  that  the  pulps  are  dead  in  some 
of  the  nearby  teeth,  he  will  no  doubt  have  gone  a  long  way 
in  doing  a  great  deal  of  good  to  his  patient  in  preventing 
the  continuance  of  this  state  of  affairs. 

Diagnosis  and  Methods  of  Examination 

Diagnosis.— Speaking  of  the  diagnosis,  it  is  usually 
simple  enough.  It  is  not  only  necessary  to  determine 
that  a  man's  jaw  has  been  broken,  but  it  is  also  equally 
important  to  make  out  the  line  or  lines  of  fracture,  in 
order  to  know  the  parts  that  are  involved.  Now  of  course 
modern  surgery  teaches  and  demands  that  a  radiograph 
be  made  of  all  cases,  but  an  army  dentist  will  be  in  a  po- 
sition, many  times  no  doubt,  where  an  X-ray  machine 
will  not  be  at  hand.  Therefore  it  is  quite  necessary  to 
map  out  some  method  of  making  an  examination  and 
adhering  to  it.  One  good  way  to  make  out  the  line  of 
fracture  and  the  extent  of  it  is  by  palpation. 

Palpation. — The  following  is  the  method  used  by  the 


FRACTURES  OF  UPPER  JAW  203 

writer  to  determine  the  area,  extent  and  lines  of  fractures 
of  the  maxillary  bones.  Standing  in  front  of  the  patient, 
the  fingers  of  the  left  hand  are  used  in  the  mouth  and 
the  fingers  of  the  right  hand  outside  the  mouth  in  ex- 
amination of  the  patient's  left  jaw.  The  position  of  the 
left  and  right  hand  fingers  is  reversed  when  examining 
the  patient's  right  jaw.  Beginning  the  digital  examina- 
tion in  the  joint  region  on  the  left  side  and  following 
the  surfaces  of  the  bone  continuously  the  right  joint  is 
reached.  It  is  not  necessary  nor  is  it  good  surgery  to 
skip  about  from  this  place  to  that  while  palpating  to 
elicit  crepitus.  The  index  finger  is  placed  in  the  mouth 
on  the  internal  surface  of  the  ramus  as  far  up  as  one  can 
go  and  the  tissues  are  pressed  from  the  outside  gently,— 
the  word  gently  must  be  emphasized  for  reasons  stated 
earlier,  namely, — to  avoid  pain  and  infection.  Pressing 
the  tissues  from  the  outside  against  the  index  finger  that 
is  within  the  patient's  mouth,  and  placing  the  ear  close 
to  the  patient's  face  (particularly  from  the  angle  to  the 
joint)  one  may  elicit  crepitus  by  the  sound.  When  press- 
ing and  pulling  to  determine  the  line  of  fracture,  the  frag- 
ments can  be  moved  in  every  possible  direction,  but  not 
violently.  In  this  way  the  exact  area,  extent  and  lines 
of  fracture  will  probably  be  determined  in  every  instance. 
Fractures  in  Military  Life.— It  is  very  important  to 
remember,  when  this  examination  is  made,  that  a  bullet 
may  have  destroyed  osseous  tissues  in  one  area  causing 
a  compound  fracture  and  in  another  part  of  the  jaw  there 
may  be  a  simple  fracture  as  the  result  of  the  transmitted 
force,  or  by  a  fragment  of  bone  acting  as  a  secondary 
projectile.  Generally  speaking,  in  most  fractures  of  the 
upper  jaw  in  civil  life,  there  is  no  loss  of  osseous  or 
soft  tissue,  the  prognosis  is  very  favorable  and  there  is 
no  functional  impairment  nor  anatomical  deformity;  but 
in  the  cases  seen  in  military  life  there  is  no  question  but 
that  there  is  a  great  loss  of  hard  tissue,  with  the  result- 
ing dropping  in  of  the  bridge  of  the  nose  and  lower  bor- 


204     MAXILLARY  FRACTURES  (SURGICAL) 

ders  of  the  face  in  those  cases  where  the  palatal  and  al- 
veolar processes  have  been  entirely  shot  away.  It  is  a 
strange  thing  that  many  of  these  cases  have  not  been 
followed  by  extensive  loss  of  soft  tissue.  The  wound 
may  appear  very  wide  and  the  dentist  may  feel  that  he 
is  incapable  of  uniting  that  wound  with  any  degree  of 
success  by  plastic  operations  or  by  the  use  of  splints. 
It  must  be  remembered,  however,  that  that  wound  ap- 
pears much  wider  than  it  would  appear  if  the  contracted 
tissues  were  in  a  normal  condition.  The  borders  of  the 
wound  are  contracted  because  of  the  injury  ;  the  products 
of  inflammation  and  infection  have  further  contracted  it 
and,  as  a  result  of  the  fracture,  the  traction  balance  is 
lost,  all  of  which  causes  a  gaping  wound.  So,  the  point 
to  be  borne  in  mind  in  the  facts  just  stated  is  that  appar- 
ently large  wounds  may — after  the  products  of  inflam- 
mation have  departed,  the  wound  treated  and  cleansed 
and  splints  and  appliances  used — not  amount  to  a  great 
deal  in  the  way  of  anatomical  disfigurement. 

Removing  Foreign  Bodies  and  Maintaining  Asepsis 

Oral  Asepsis.— Now,  of  course,  it  is  always  desirable 
to  remove  a  foreign  body,  but  when  to  do  it  is  the  ques- 
tion. That  depends  on  the  experience  and  judgment  of 
the  operator;  the  vitality  of  the  patient;  the  condition 
of  the  wound  and  the  extent  of  the  operation.  It  might 
be  said  here,  in  connection  with  pneumonia,  that  at  most 
of  the  hospitals  it  has  been  found  that  septic  pneumonia 
has  followed  in  every  case  in  which  the  patient  had  taken 
ether  for  some  surgical  condition  before  having  had  his 
jaws  operated  upon.  This  is  the  strongest  evidence  for 
the  cleansing  of  the  oral  cavity  before  any  major  opera- 
tion. This  fact  above  everything  else,  shows  us  the  im- 
portance of  keeping  the  mouths  of  these  men  clean,  be- 
cause their  jaws  have  lost  functional  capacity  and  for 
the  time  being  the  patients  are  mouth  breathers  and  are 


FRACTURES,  OF  UPPER  JAW  205 

constantly  inspiring  air  vitiated  with  septic  matter.  In 
many  instances,  when  an  operation  has  been  performed, 
men  have  been  given  morphin  and  have  lost  their  laryn- 
geal reflexes,  with  the  result  that  they  have  actually  in- 
spired septic  matter.  It  is  very  evident  therefore  that 
thorough  cleansing  of  the  mouth  is  the  first  thing  to  be 
done.  The  mouth  and  tissues  must  be  kept  in  as  clean  a 
condition  as  is  possible,  because  the  results  obtained  are 
always  in  direct  relation  to  the  amount  of  asepsis  main- 
tained in  the  surgeon's  technique.  For  the  same  reasons 
that  the  treatment  of  root  canals  or  the  extraction  of 
teeth  is  attended  with  far  better  results  when  every 
method  is  used  to  ensure  asepsis,  so  also  the  best  results 
are  no  doubc  obtained  here  by  absolute  cleanliness. 

Time  for  Removing  Foreign  Bodies.— When  a  man  is 
suffering  from  a  great  deal  of  shock,  fatigue  and  low 
resistance,  it  is  folly  to  try  to  remove  a  foreign  body  but 
the  time  for  removing  it,  as  has  been  said  before,  is  de- 
termined by  the  patient's  condition,  the  extent  of  the 
operation  and  the  involvements  and  size  of  the  wound. 
If  the  operation  be  a  minor  one  and  one  which  can  be 
done  under  novocain,  this  may  be  performed  without 
injuring  that  man's  physical  or  nervous  system  to  any 
appreciable  extent;  but  if  it  be  one  of  those  extensive 
fractures,  involving  the  removal  of  a  number  ef  pieces 
of  bone,  and  if  the  patient  be  in  a  low  state  or  just  re- 
covering from  pneumonia,  removal  of  a  foreign  body 
should  not  be  attempted.  On  the  contrary  the  dentist 
should  attempt  to  keep  the  mouth  clean,  having  it  syr- 
inged at  stated  intervals  so  that  the  patient  may  not 
swallow  and  ingest  the  accumulating  pus. 

Cleansing  the  Mouth.— Speaking  about  cleanliness,  the 
use  of  sulphonapthol  is  about  as  efficient  and  economical 
as  anything  that  there  is  in  the  pharmacopeia.  The 
parts  should  be  rubbed  well  with  a  solution  com- 
posed of  iodin  crystals  ten  parts;  menthol  crystals  ten 
parts;  benzol  one  hundred  parts.    In  applying  this  iodin 


206     MAXILLARY  FEACTUEES  (SUKGICAL) 

preparation  it  should  not  be  painted  lightly,  as  is  often 
done  when  making  an  injection  with  novocain,  but 
rather  applied  with  vigor  in  order  to  get  not  only  the 
medicinal,  therapeutic  values  of  the  solution,  but  the 
mechanical,  f rictional,  cleansing  effect,  rubbing  it  in  well 
and  wiping  the  parts  first  with  alcohol.  Before  this  is 
done  the  patient  should  gargle  the  throat  and  rinse  the 
mouth  well,  vigorously  using  the  cheeks  as  a  bellows, 
thus  mechanically  flushing  out  the  debris  and  the  pus 
products  that  are  constantly  forming.  It  is  perfectly 
well  known  to  all  that  no  antiseptic  or  germicide  that  can 
be  borne  by  the  tissues  is  in  the  mouth  long  enough  to 
actually  kill  germs  for  it  takes  acids  or  boiling  for  twenty 
minutes  to  kill  the  organism  with  its  spore  formation. 
This  is  the  chief  reason  for  vigorous,  mechanical  irri- 
gation. 

Value  of  Iodin. — As  an  experiment  to  bear  out  what 
has  been  said  about  the  iodin  solution,  the  next  time  the 
reader  extracts  a  number  of  teeth,  let  him  have  the  pa- 
tient rinse  the  mouth  as  he  has  ordinarily  done  in  the 
past.  Then  let  him  select  a  few  of  the  teeth  and  rub  this 
iodin  solution  well  into  the  mucous  membrane  about  them, 
and  inject  iodin  gently  into  the  pockets  if  pyorrhea  is 
present,  and  note  the  difference  in  the  way  those  gums 
heal  in  comparison  to  the  tissues  where  this  treatment 
is  not  followed.  If  this  is  done  once  the  experimenter 
will  never  extract  a  tooth  without  following  this  line  of 
procedure  or  a  somewhat  similar  one,  equally  effective 
from  the  standpoint  of  surgical  asepsis. 

Feeding 

In  the  feeding  of  these  cases,  the  liquid  diet  is  the  only 
thing  which  can  be  used  for  a  time.  It  all  depends  upon 
wdiat  splints  are  used,  as  to  whether  the  diet  will  be 
liquid  or  whether  it  will  be  semi-solid.  Of  course,  too,  the 
extent  of  the  injury  and  the  loss  of  functions  of  the  jaws 


FRACTURES  OF  UPPER  JAW  207 

as  the  result  of  the  wound  are  factors  that  are  to  be  con- 
sidered in  determining  upon  the  diet  to  be  used.  In  this 
liquid  diet  it  is  sometimes  necessary  to  feed  through  the 
nose.  No  attempt  should  be  made  to  feed  a  man  through 
the  nose  before  this  organ  has  been  well  cleansed,  and 
after  cleansing  it,  the  cavity  must  be  sprayed  with  a 
two  per  cent  novocain  or  a  one  per  cent  cocain  solution. 
This  is  quite  important  in  feeding  with  a  tube  through 
the  nose,  if  the  patient  is  to  be  given  any  degree  of 
comfort. 

Taking  Impressions 

As  a  general  rule  it  may  be  said  that  it  is  best  to  take 
impressions  for  working  models  in  modeling  compound. 
Some  men  advocate  the  use  of  plaster.  However,  this  is 
unnecessary  because  it  causes  a  great  deal  of  discomfort 
to  the  patient  and  some  of  the  plaster  is  apt  to  run  down 
the  lines  of  fracture  and  this  may  be  very  difficult  to  re- 
move. The  textbooks  recommend  the  approximation  of 
the  fractured  ends  and  holding  them  in  place  while  the 
impressions  are  taken.  This  is  quite  a  difficult  thing  to 
do  and  one  may  consider  himself  very  fortunate  when 
taking  an  impression  of  a  fracture  case  if  he  gets  clear- 
cut,  well-defined  impressions  of  the  teeth  alone,  to  say 
nothing  of  being  able  to  hold  the  ends  of  the  fragments 
together  while  taking  the  impression.  When  the  opera- 
tor does  approximate  and  manipulate  the  fragments,  he 
should  bear  in  mind  that  he  must  be  as  gentle  as  possible, 
for  reasons  which  have  been  mentioned  before.  The  oral 
cavity  and  the  line  of  fracture  should  be  flushed  out 
gently  in  order  not  to  move  decomposed  matter  to  such 
an  extent  as  to  open  another  avenue  of  infection. 

Irrigation. —While  speaking  of  irrigation,  it  might  be 
mentioned  that  in  cases  of  fracture  with  antral  involve- 
ment, one  must  spray  or  irrigate  very,  very  gently  to 
avoid  forcing  septic  matter  into  the  accessory  air  sinu- 
ses, thereby  doing  the  patient  more  harm  than  good.  The 


208    MAXILLARY  FRACTURES  (SURGICAL) 

solution  should  always  be  warm.  The  use  of  peroxid  of 
hydrogen  should  be  discouraged  in  this  class  of  cases, 
and,  in  fact,  in  any  abscessed  tract,  especially  if  that  tract 
has  no  fistulous  opening.  Any  surgeon  who  has  had 
much  experience  with  peroxid  of  hydrogen  does  not  wish 
to  use  it  on  account  of  the  possibility  of  opening  a  new 
avenue  of  infection.  The  free  atoms  of  oxygen  are  lib- 
erated and  these  have  an  affinity  for  the  canaliculae  of  the 
bones,  leaving  them  open  and  allowing  ready  ingress  for 
pus  and  other  infectious  matter.  Therefore  the  use  of 
peroxid  of  hydrogen  is  contra-indicated. 

ANESTHESIA 

Novocain  and  Supraeenin 

Local  Anesthesia.— It  may  not  be  out  of  place  to  say 
here  just  a  few  words  about  novocain,  since  it  will  be 
much  used  in  connection  with  treatment  of  fractures.  No 
one  should  attempt,  of  course,  to  set  a  fracture  of  the 
lower  jaw,  anterior  to  the  angle,  without  a  mandibular 
injection  on.  the  same  side  and  a  mental  injection  on  the 
opposite  side  to  the  seat  of  the  fracture.  Nor  should  any- 
one attempt  to  set  a  fracture  of  the  superior  maxilla 
without  proper  conductive  local  anesthesia.  Local  anes- 
thesia is  preferable  to  general  because  there  is  less  haz- 
ard of  septic  pneumonia. 

Proper  Care  in  Injection.— The  causes  of  after-pain  fol- 
lowing an  injection  are:  (a)  unclean  syringes  and 
needles;  (b)  unclean  technic;  (c)  stale  or  unsterile  solu- 
tion; {d)  alcohol  in  the  syringe;  (e)  too  much  of  the 
solution;  (/)  injecting  the  solution  too  rapidly;  (g)  in- 
jecting into  the  muscular  tissue.  If  all  of  these  causes  are 
eliminated  it  is  certain  that  there  will  be  little  or  no  after- 
pain  from  novocain  injections.  The  writer  believes  that 
many  men  use  too  much  of  the  solution  for  a  given  injec- 
tion and  that  it  acts  as  a  mechanical  irritant,  even  though 


ANESTHESIA  209 

Fischer  and  others  claim  the  solution  is  isotonic.  The 
writer  is  also  of  the  opinion  that  the  depression  that 
sometimes  follows  one  of  these  injections  is  due  chiefly 
to  the  supra  renin.  It  can  readily  be  understood  that  the 
tissues  cannot  absorb  and  diffuse  two  cubic  centimeters 
as  readily  as  they  can  one  cubic  centimeter.  Therefore 
in  a  solution  in  which  the  strength  of  the  novocain 
only  has  been  increased  there  will  be  less  irritation  with 
a  smaller  quantity  of  the  drug-  and  the  depression  will 
not  be  greater  because  there  is  no  increase  in  the  quantity 
of  the  suprarenin,  which,  of  course,  is  the  depressing 
agent  in  novocain  injections.  To  overcome  these  two  last 
named  difficulties,  irritation  and  depression,  the  quantity 
of  the  solution  must  be  cut  down  but  the  strength  in- 
creased. In  increasing  the  strength  of  the  solution  it  is 
done  with  an  F  tablet,  which  contains  no  suprarenin. 
For  instance,  it  is  preferable  to  use  alec,  solution  con- 
taining an  E  and  F  tablet  rather  than  to  use  a  2  c.  c.  solu- 
tion containing  one  E  tablet.  In  this  way  a  stronger 
anesthetic  solution  is  obtained.  There  is  also  less  danger 
of  the  solution  acting  as  a  foreign  body,  on  account  of  the 
quantity  having  been  halved.  If  uncleanliness  is  elim- 
inated, the  suprarenin  reduced  and  the  principles  of  the 
injection  teclmic  just  outlined  followed,  it  will  be  found 
that  novocain  is  a  great  boon  to  the  patient  and  to  the 
operator.  It  lessens  pain  and  reduces  disagreeable  after 
effects. 

Technic— A  few  words  upon  the  teclmic  of  injection 
will  be  said  here.  It  is  taken  for  granted  that  syringe, 
needle  and  contents  have  been  sterilized.  It  must  be  in- 
sisted that  the  patient  gargle  his  throat  and  flush  his 
mouth,  using  the  cheeks  as  a  bellows  to  accomplish  thor- 
ough irrigation.  Alcohol  is  applied  on  the  area  in 
which  the  needle  is  to  be  inserted  and  the  iodin  solu- 
tion well  rubbed  in  to  get  mechanical,  frictional  cleans- 
ing and  tanning  of  the  area.  The  needle  is  inserted 
slowly,  pushing  the  contents  of  the  syringe  ahead  of  the 


210     MAXILLARY  FRACTURES  (SURGICAL) 

needle  and  depositing  the  solution  slowly  so  that  after- 
pain  and  unpleasant  sequelae  may  be  under  control.  The 
bone  is  followed.  The  needle  is  removed  and  care  taken 
that  it  is  sterilized  before  making  another  insertion  in 
the  immediate,  adjacent  or  distant  tissues.  Often  men 
will  use  the  utmost  care  in  the  preparation  of  their 
syringe,  needle  and  solution,  and  yet,  if  they  have  not 
used  the  entire  contents  of  the  barrel,  will  commit  the 
grave  error  of  making  a  second  insertion  without  ster- 
ilizing that  needle.  Some  practitioners  like  platinum 
needles,  others  prefer  the  steel.  The  claims  set  forth 
for  the  platinum  needles  are  ease  of  sterilization  and  that 
they  are  not  likely  to  break.  The  disadvantages  of  the 
platinum  needles  are  that  they  easily  become  dull  and 
often  bend  while  being  inserted,  which  brings  about  loss 
of  direction  in  depositing  the  solution.  The  writer  uses 
a  new  steel  needle  for  each  barrel  content.  It  is  always 
sharp,  it  costs  eight  cents,  it  is  worth  eight  cents,  for  it 
has  done  its  duty,  and  there  is  less  likelihood  of  breaking 
one  off  in  the  succeeding  patient's  mouth  if  it  is  used  but 
once  and  thrown  away.  Steel  needles  rarely  break  in  the 
hands  of  a  careful  operator  and  if  they  do,  his  technic 
is  so  under  control  that  they  are  not  lost  in  the  tissues 
but  are  easily  removed. 

Regulation  of  Bowels  Necessary.— It  should  be  said 
that,  in  fracture  cases,  on  account  of  the  loss  of  chewing 
capacity  by  the  patient,  it  is  necessary  that  the  bowels  be 
kept  well  regulated.  The  absorption  of  toxins,  etc.,  is 
always  to  be  guarded  against,  and  this  matter  is  a  very 
important  part  of  the  treatment  of  a  case. 


TREATMENT  OF  THE  FRACTURE 

Importance  of  Reduction  and  Maintaining  Fixation.— 
There  is  one  point  which  should  be  emphasized,  namely, 
that  reduction  of  the  fracture  is  the  condition  to  be  aimed 


FRACTUBES  OF  THE  MANDIBLE  211 

at  all  the  time  during  the  healing,  and  by  all  means  main- 
tained by  fixation.  If  the  splint  should  come  off  it  must 
be  put  on  again  as  soon  as  possible,  always  bearing  in 
mind  the  ever-present  condition  that  may  occur,  and  that 
is  infection.  To  prevent  infection  and  re-infection  the 
spicules  of  bone  must  be  removed  and  cleanliness  main- 
tained by  frequent  gentle  irrigation  with  warm  solutions. 
Drooling. — Drooling  is  a  very  annoying  condition 
which  accompanies  practically  all  maxillary  fractures.  A 
very  good  method  of  handling  this  condition  is  as  fol- 
lows :  one  end  of  a  napkin  or  handkerchief  is  taken  and 
the  patient  holds  one  corner  of  it  between  the  inner  sur- 
face of  the  lower  lip  and  the  labial  gum,  over  the  incisor 
region  of  the  lower  jaw.  If  it  is  allowed  to  hang  down 
as  directed  this  drooling  will  be  controlled.  Some  men 
pack  the  month  under  and  along  the  tongue  with  gauze 
but  if  the  method  just  suggested  is  followed  the  patient 
will  not  be  annoyed  with  drooling  to  any  great  extent. 


FRACTURES   OF  THE    MANDIBLE 

Displacements 

Fractures  of  the  mandible,  even  in  civil  life,  are  com- 
pound as  a  rule.  This  jaw  is  more  frequently  fractured 
than  the  upper  jaw,  because  it  is  not  protected  so  well 
anatomically  and  is  therefore  more  exposed  to  the  vari- 
ous forms  of  violence.  In  one  case  seen  the  fracture 
occurred  between  the  cuspid  and  the  first  bicuspid  on  the 
lower  jaw,  with  the  long  fragment  drawn  down  and  the 
shorter  one  drawn  up.  This  introduces  a  very  important 
point,  namely,  displacement  and  a  study  of  muscular 
traction. 

Typical  Case.— To  make  the  description  and  study  of 
displacement  as  clear  as  possible,  a  case  will  be  cited. 
The  fracture  is  between  the  lower  right  cuspid  and  first 
bicuspid.    The  long  fragment  in  this  case  has  both  pairs 


212     MAXILLARY  FRACTURES  (SURGICAL) 


of  superior  and  inferior  genial  tubercles.  Therefore 
there  will  be  a  downward,  inward  and  backward  displace- 
ment of  the  long  fragment  and  an  upward  and  outward 
displacement  of  the  short  fragment,  because  the  balance  of 
muscular  traction  has  been  lost.  The  long  fragment  as- 
sumes the  position  stated,  on  account  of  the  action  of  the 
geniohyoid,  the  geniohyoglossus  and  the  anterior  belly  of 
the  digastric.  The  shorter  fragment  takes  the  position  de- 
scribed because  of  the 
traction  of  the  strong 
masseter  and  the  in- 
ternal pterygoid  mus- 
cles. With  this  case 
firmly  fixed  in  mind 
the  reader  will  have  a 
pretty  good  idea  of 
the  position  of  the 
fragments  following 
a  fracture  in  this 
area.  A  fairly  good 
conception  as  to 
where  the  line  of 
fracture  is  located 
should  always  be 
gained  by  a  study  of 
the  anatomical  and 
muscular  relations. 
To  make  the  descrip- 
tion more  clear, — if  the  fracture  was  in  the  median  line, 
between  the  superior  and  inferior  genial  tubercles  on 
one  side  and  those  on  the  other  there  would  be  little  or 
no  displacement  because  the  muscular  traction  balance 
would  not  have  been  upset  to  any  extent.  By  making  a 
study  of  the  muscles  involved  in  the  area  of  a  fracture, 
and  by  being  familiar  with  their  actions,  much  time  may 
be  saved  in  mapping  out  the  line  of  fracture,  and  in  de- 
ciding upon  what  type  of  splint  is  practical. 


Fig.  85. — Study  of  Displacement.  Frac- 
ture between  lower  right  cuspid  and 
first  bicuspid.  Long  fragment  displaced 
downward,  short  fragment  displaced 
upward. 


FRACTURES  OF  THE  MANDIBLE 


213 


Fractures  at  the  Angle  of  the  Mandible.— Fractures  at 
the  angle  of  the  mandible  are  prone  to  little  or  no  dis- 
placement, because  the  masseter  muscle  as  a  rule  has 
fibers  inserted  on  either  side  of  the  line  of  fracture  and 
the  strength  of  this  muscle  is  well  known.  This  is  the 
reason  why  it  is  difficult  sometimes  to  make  out  crepitus 


Pig.  86. — Fracture  Anterior  to  Angle  with  Characteristic  Little 
Displacement.  A  and  B  indicate  spicules  of  bone;  G  indicates  line 
of    fracture. 


in  a  fracture  at  the  angle  of  the  mandible.  Other  con- 
ditions that  add  to  the  difficulty  in  examination  in  this 
area  are  the  induration  and  swelling  of  the  tissues. 
Therefore,  considerable  study  should  be  undertaken  on 
the  causes  of  extreme  and  minor  muscular  traction,  be- 
cause this  has  a  great  deal  of  bearing  on  the  type  of 
splint  or  method  to  be  resorted  to  in  bringing  about 


214     MAXILLARY   FRACTURES  (SURGICAL) 

reduction,  maintaining  fixation  and  getting  a  fairly  nor- 
mal occlusion  of  the  teeth.  In  obtaining  a  favorable 
result  as  far  as  occlusion  goes,  we  may  not  be  able 
to  produce  that  idealistic  orthodontic  occlusion  which  is 
read  of  in  the  text-books,  but  the  lines  of  occlusion  should 
be  so  well  fixed  when  a  fracture  is  set  that  it  will  com- 
pa  re  favorably  with  the  occlusion  that  was  present  before 
the  fracture  occurred.  In  some  cases  a  far  better  occlu- 
sion of  the  teeth  may  be  secured  in  the  finished  case 
that  the  patient  possessed  before  the  fracture  took  place, 
without  endangering  the  symmetry  of  the  face. 

Splints 

Use  of  the  Skull  Cap.— The  first  surgical  principle  in 
the  treatment  of  every  fracture  is  rest. 

To  assist  in  maintaining  rest,  for  the  first  few  days, 
while  the  splints  are  being  made  and  after  they  have 
been  put  in,  a  skull  cap  should  be  used  in  every  case.  In 
making  one  of  these  skull  caps,  the  main  point  to  be  borne 
in  mind  is  that  the  two  small  flaps  to  which  the  buckles 
are  attached  and  which  are  sewed  to  the  piece  of  webbing 
that  encircles  the  head,  should  be  stitched  to  this  web- 
bing at  such  an  angle  that  when  the  piece  of  webbing 
supporting  the  chin  is  attached  to  these  buckles,  the 
force  will  be  exerted  in  a  plane  that  extends  from  the 
mental  prominence  to  the  glenoid  cavity.  This  is  ex- 
tremely important  when  the  skull  is  used  for  anchorage. 
It  is  always  necessary  to  use  one  of  these  skull  caps,  or 
some  similar  device,  when  making  use  of  the  interdental 
vulcanite  splints  which  are  often  used  in  extensive  frac- 
tures. If,  when  inserting  one  of  these  interdental  vul- 
canite splints,  it  does  not  appear  to  fit,  and  the  frag- 
ments cannot  be  fitted  into  place,  the  operator  need  not 
feel  discouraged.  He  should  bring  about  as  much  reduc- 
tion as  possible  and  hold  it,  tightening  on  the  buckles. 
The  next  day,  when  the  patient  comes  in,  one  may  be 


FRACTURES  OF  THE  MANDIBLE  215 

greatly  surprised  and  pleased  to  notice  that  the  frag- 
ments have  settled  into  correct  position  or  nearly  so. 
This  has  happened  in  the  writer's  experiences  so  fre- 
quently that  it  is  not  at  all  disappointing  if  the  parts 
do  not  go  into  place  on  the  first  visit  of  the  patient.  On 
account  of  infiltration  of  the  tissues  with  the  products  of 
inflammation  and  because  of  muscular  traction,  it  is  not 
likely  that  the  fragments  should  go  easily  into  place  but, 


Fig.  s". — Front  axd  Lateral  Views  op  Skull  Cap  ix  Position.  Straps 
adjusted  to  show  necessity  of  exerting  pressure  in  a  plane  from  the 
mental  prominence  to  the  glenoid  fossa. 

with  the  surgical  rest  that  intervenes  between  the  first 
and  second  visits,  the  swelling  and  inflammation  having 
been  greatly  reduced,  the  fragments  will  slip  more  easily 
into  position. 

While  the  subject  of  splints  is  under  discussion  it  might 
be  well  to  say  that  the  ideal  splint  for  a  given  case  is  one 
so  constructed  that  the  dentist  may  watch  the  occlusion, 
maintain  cleanliness,  allow  the  patient  use  of  the  jaws 
in  the  mastication  of  soft  substances,  and  all  the  time 
control  reduction  by  maintaining  fixation.  With  the 
interdental   vulcanite  splint,  assisted  by  the  skull  cap, 


216     MAXILLARY  FRACTURES  (SURGICAL) 

reduction  is  held,  but  watching  the  occlusion  and  promot- 
ing cleanliness  are  lost  sight  of  to  a  great  extent  and 
mastication  is  impossible.  With  the  aluminum  jacket 
splint  it  is  possible  to  keep  the  parts  clean,  hold  reduc- 
tion and  allow  the  patient  some  use  of  his  jaws,  but  it 
is  not  possible  to  control  the  occlusion  to  the  same  degree 
that  might  be  accomplished  with  the  bands  to  which 
bars  have  been  soldered.  The  use  of  wires  alone,  not  in 
connection  with  bands,  is  advised  as  a  temporary  tech- 
nique only.  For  maintaining  fixation  permanently  they 
are  too  irritating. 

This  in  a  very  few  words  describes  the  whole  story  of 
the  various  types  of  splints  and  their  values.  Every 
splint  used  is  a  modification  or  combination  of  any  one 
or  all  of  these.  The  selection  of  the  splint,  the  type  to  be 
used,  the  modification  and  its  adaptation  depend  upon  the 
experience,  judgment  and  ingenuity  of  the  operator,  and 
in  the  practice  of  dental  surgery  there  is  nothing  more 
fascinating,  more  interesting  and  satisfying,  than  to 
mould  a  misshapen  and  disfigured  countenance  back  to 
its  normal  appearance. 

Study  of  Recoil 

Fractures  Where  Teeth  are  Missing.— A  very  common 
site  of  fracture  is  where  one  of  the  molar  teeth  is  missing. 
In  such  a  case  the  man  may  have  received  the  blow  on  the 
opposite  side  and  with  one  of  the  molar  teeth  missing  on 
the  near  side,  the  recoil  spends  itself  at  the  weakest  part 
of  the  bone, — namely,  where  the  tooth  is  out.  In  exam- 
inations it  is  necessary  to  study  thoroughly  by  palpation 
areas  where  teeth  are  missing  and  to  grasp  the  fact  also 
that  while  a  man  apparently  has  but  one  fracture  there 
may  be  another  on  the  opposite  side,  where  the  jaw  has 
been  weakened  by  previous  extraction  of  a  tooth.  A 
fracture  may  also  be  present  in  the  condyle  area  as  a 
result  of  this  recoil.    This  is  a  very  important  and  inter- 


FRACTURES  OF  THE  MANDIBLE 


217 


esting  study  and  a  condition  that  is  commonly  found. 
Fractures  of  Symphysis.— Fractures  of  the  symphysis 
in  the  median  line  have  little  or  no  displacement  as  a 
rule,  for  reasons  stated  earlier.  Such  a  case  could  be 
treated  by  banding  the  laterals  and  cuspids  on  either  side 


Fig.  88. — Fracture  at  the  Neck  of  the  Condyle. 


of  the  line  of  fracture,  and,  having  soldered  a  bar  both 
labially  and  lingually  to  these  bands,  cement  them  to  the 
teeth  and  thus  bring  about  reduction.  Always  assist  in 
maintaining  fixation  for  a  few  days  by  the  use  of  the 
skull  cap. 


21S     MAXILLARY  PKACTURES  (SURGICAL) 

Fracture  at  the  Neck  of  the  Condyle 

Fractures  of  the  coronoid  processes  are  rare.  Frac- 
tures at  the  neck  of  the  condyle,  while  not  common,  are 
found  sufficiently  often  to  bear  in  mind  that  they  may 
occur.  An  x-ray  picture  of  such  a  fracture  is  shown  (Fig. 
.88).  While  discussing  fractures  at  the  neck  of  the  con- 
dyle, it  might  be  well  to  give  the  differential  diagnosis 
between  it  and  a  dislocation. 


Fig.  89. — Showing  Bands,  Bar  and  Intermaxillary  Elastics  in  the 
Treatment  of  a  Case  in  which  both  Condyle  and  Body  of  the  Man- 
dible have  been   Fractured.      (From  Brophy  \s  "Oral  Surgery.") 

Differential  Diagnosis.— In  fracture  at  the  neck  of  the 
condyle  the  jaw  is  always  displaced  to  the  same  side  on 
which  the  condyle  is  fractured,  while  in  a  dislocation  the 
displacement  is  always  toward  the  opposite  side.  To 
make  it  a  little  more  clear, — if  there  is  a  fracture  of  the 
left  condyle,  the  displacement  is  toward  the  left  side.  If 
on  the  contrary  there  is  a  dislocation  of  the  left  jaw,  the 
displacement  is  toward  the  right  side. 

Treatment  of  Condyloid  Fracture.— The  treatment  of 
a  case  of  fracture  at  the  neck  of  the  condyle  on  the  left 
side  with  another  fracture  between  the  lower  right  bicus- 
pids on  the  opposite  side  was  as  follows:     Bands  were 


FRACTURES  OF  THE  MANDIBLE 


219 


made  to  encircle  two  of  the  tfeth  on  either  side  of  the 
fracture  in  the  bicuspid  region  and  strong  metal  bars 
were  soldered  both  labially  and  lingually  to  these  bands. 
These  bauds  were  cemented  to  the  teeth  and  thus  this 
bicuspid  fracture  was  reduced  and  fixed.    If  the  operator 


Fig.  90. — Extensive  Necrosis.     Showing  dangers  of  inviting  pathological 
fracture  by  radical  operation  for  the  removal  of  sequestra. 


had  used  a  vulcanite  splint  and  controlled  immobility  it 
can  readily  be  seen  that,  while  the  fracture  at  the  neck  of 
the  condyle  was  uniting,  adhesions  might  form  in  the  tem- 
poromandibular region,  with  resulting  ankylosis.  To 
prevent  the  possibility  of  such  a  condition  arising,  inter- 
maxillary elastics  were  employed,  such  as  are  used  in 
orthodontia  cases.     It  is  not  necessary  to  describe  the 


220     MAXILLARY  FRACTURES  (SURGICAL) 

insertion  and  attachments  of  these  for  the  technique  is 
known  to  all. 

In  studying  this  case  a  little  more  closely,  it  may  be  said 
that  in  the  bicuspid  fracture  fixation  of  the  parts  and  nor- 
mal occlusion  were  maintained ;  the  area  was  kept  clean 


Fig.  S>1. — Extensive  Necrosis.     Same  as  Figure  90.     (Six  months  later.) 
Showing  result  of   conservative   treatment  of   extensive   necrosis. 


easily  and  the  patient  enjoyed  the  use  of  his  jaws  in  the 
mastication  of  very  soft  solids  and  by  the  continued 
force  of  the  maxillary  elastics  the  head  of  the  condyle 
was  given  some  degree  of  motion.  This  is  a  very  clever 
and  ingenious  way  of  handling  conditions  of  this  sort. 
Another  point  that  this  case  strongly  emphasizes  is  this, 
— that  before  the  operator  makes  up  his  mind  what  splint 


FRACTURES  OP  THE  MANDIBLE  221 

he  should  use  he  must  have  every  fracture  definitely,  ac- 
curately and  clearly  outlined. 

Danger  of  Pathological  Fracture.— A  case  in  which 
necrosis  is  present  and  which  involves  the  body  of  the 
bone  from  the  angle  on  one  side  to  the  angle  on  the  other 
is  next  studied  (Figs.  90  and  91).  Here  it  was  feared  that 
if  a  radical  operation  were  performed,  as  is  often  done  in 
necrosis  cases,  and  an  attempt  was  made  to  remove  all  the 
dead  bone,  the  remaining  healthy  bone  might  be  weakened 


Fig.  92. — Pathological  Fracture.  Upper  right  hand  picture  shows  frac- 
ture in  body  of  bone.  Lower  picture  shows  molar  tooth,  removal  of 
which,  with  pus  formation,  so  weakened  the  bone  that  fracture  followed. 

to  such  an  extent  that  the  man  might  suffer  a  fracture 
or  fractures  of  this  delicate  horseshoe-shaped  piece  of 
bone,  with  permanent  loss  of  function  and  unsightly  dis- 
figurement, because  it  would  be  impossible  to  unite  the 
fragments  so  that  the  lower  borders  of  the  face  might 
be  restored  to  anywhere  near  their  correct  anatomical 
position.  Such  a  type  of  fracture  is  styled  a  pathologi- 
cal fracture  and  is  not  the  result  of  direct  violence,  but 
is  caused  by  a  functional  force  exerted  upon  a  bone  weak- 
ened by  disease.  Rather  than  perform  this  radical  oper- 
ation it  was  decided  in  this  case  to  act  very  conserva- 


222     MAX  1 1, LAKY  FRACTURES  (SURGICAL) 

tively  and  remove  the  sequestra  as  they  formed.  The 
parts  were  kept  as  clean  as  possible  by  frequent  irriga- 
tion and  light,  delicate  cnrettement  and  the  area  stimu- 
lated now  and  then  with  aromatic  sulphuric  acid  applied 
on  a  piece  of  cotton.  The  man  was  given  a  Moffatt  syringe 
with  instructions  in  its  use  and  advised  not  to  swallow 
any  of  the  constantly  accumulating  pus.     (Figs.  90,  91.) 


EXTERNAL    INCISIONS,    PREVENTION    OF    POINT- 
ING AND   DRAINAGE 

The  writer  of  this  chapter  does  not  wish  to  discourage 
the  attempts  that  have  been  made  in  the  past  to  teach 
students  not  to  make  an  incision  externally  upon  the 
face,  but  every  rule  has  its  exception,  and  it  would  be 
far  better  surgery  in  some  cases  to  make  a  small  in- 
cision externally  upon  the  face  with  the  resulting  mini- 
mum disfigurement.  It  must  be  stated,  however,  that  in 
the  vast  majority  of  conditions  met  with  in  dental  and 
oral  surgery,  an  incision  within  the  oral  cavity  is  all  that 
is  required  to  gain  free  and  complete  drainage.  When 
an  incision  is  to  be  made  externally  upon  the  face,  the 
question  of  the  position  and  possible  extent  of  the  re- 
sulting disfigurement  should  be  ever  present.  There- 
fore, before  using  the  knife,  the  cardinal  principles  of 
site,  shape,  size  and  direction  of  incision  should  be  given 
serious  consideration.  Above  all,  never  make  an  incision 
in  cross  section  to  the  fibres  of  a  muscle  In  certain  cases 
if  the  incision  were  not  made  externally  and  if  nature 
were  allowed  to  follow  her  own  course,  the  result  would 
be  a  puckered  wound  with  an  unsightly  scar. 

It  is  necessary  in  some  cases  to  make  the  incision  ex- 
ternally upon  the  face  because  the  abscess  is  pointing 
at  a  distance  of  an  inch  below  the  inferior  border  of  the 
mandible,  and  it  can  be  readily  understood  that  even 
though  free  incisions  are  made  within  the  mouth,  it  is 
quite  an  impossibility  to  thoroughly  drain  that  abscess 


EXTERNAL  INCISIONS  223 

through  the  oral  cavity.  This  may  be  compared  to  drain- 
ing a  barrel  with  the  drainage  made  through  the  middle 
of  the  side  rather  than  through  the  bottom.  An  abscess 
may  be  prevented  from  pointing  externally  upon  the  face 
by  free  incision  within  the  mouth,  by  the  use  of  the  ice 
bag  externally  and  by  supporting  the  skin  in  the  affected 
area  with  five  or  six  coats  of  collodion. 

Technique  of  Insertion  of  Wick 

In  placing  a  wick  in  a  fistulous  tract  which  extends 
from  the  inside  of  the  mouth  to  the  outside  of  the  face, 
the  following  technique  has  some  value.  After  the  wick 
has  been  put  through  the  wound  for  the  first  time,  in  the 
usual  manner,  with  a  probe, — always  from  without  in- 
ward, and  the  area  on  the  face  has  of  course  been  ster- 
ilized before  doing  this, — at  the  second  visit  of  the  pa- 
tient, before  removing  the  wrick  it  is  necessary  to  cut  off 
that  portion  of  the  wick  exposed  on  the  face  on  which 
the  discharge  from  the  wound  has  become  dry.  Next 
a  piece  of  silk  about  a  yard  long  is  tied  on  the  wick  at 
this  still  protruding  outside  end,  at  a  point  where  the 
discharge  from  the  tissues  has  not  become  dried;  then 
the  wick  is  removed  by  pulling  the  attached  piece  of  silk 
through  the  wound  into  the  mouth  and  out  through  the 
oral  orifice.  Next  the  wick  is  cut  off  from  the  floss  and 
the  ends  of  floss  tied  together.  After  the  tract  has  been 
irrigated  the  floss  silk  is  cut,  tying  the  w7ick  on  the  end 
that  comes  through  the  face.  The  floss  silk  is  grasped 
between  the  fingers  of  one  hand  and  with  the  fingers  of 
the  other  holding  the  wrick  it  is  given  a  quick  pull  in  an 
outward  inward  direction,  leaving  the  wick  in  place,  with 
little  or  no  discomfort  to  the  patient.  All  of  this  is  very 
simple  and  possibly  quite  elementary  and  yet  these  points 
in  technique  are  overlooked  many  times  by  brilliant  oper- 
ators. The  value  of  this  procedure  is  that  it  increases 
speed  and  cleanliness  and  minimizes  pain.    The  dried  end 


224     MAXILLARY  FRACTURES  (SURGICAL) 

of  the  wick  is  cut  off  because  in  pulling  it  through  the 
wound  it  would  cause  unnecessary  pain.  The  wick  is 
pulled  in  an  outward  inward  direction  so  as  to  avoid 
needlessly  placing  a  greater  number  of  microorganisms 
in  the  wound.  The  ends  of  the  floss  are  tied  together  so 
that  they  will  not  come  out  through  the  wound  when  the 
fistulous  tract  is  irrigated.  Everyone  should  remember, 
in  placing  wicks,  that  they  become  foul  quite  rapidly  and 
this  is  not  going  to  enhance  the  rapidity  of  the  healing 
process,  therefore  a  frequent  change  is  necessary.  In 
fact,  the  whole  question  of  the  surgical  treatment  of 
fractures  simmers  down  to  fundamental  mechanics  to- 
gether with  absolute  cleanliness,  careful  surgery  and 
common  sense. 

Radiographic  Precautions.— Here  it  should  be  reiter- 
ated that  it  is  not  safe  to  rely  on  one  radiograph  taken 
in  a  certain  position  but  to  have  a  number  of  them  made 
at  various  angles  in  order  to  avoid  confusion  in  the  in- 
terpretation of  the  radiograph  and  thus  escape  the  crime 
of  faulty  technique. 

Treatment  of  Scar.— In  cases  of  external  incisions  upon 
the  face,  the  amount  of  scar  may  be  minimized  by  draw- 
ing the  lips  of  the  wound  together  with  zinc  oxid  strips 
after  the  pus  flow  has  ceased,  and  also  by  not  resorting 
to  the  use  of  the  wick  unless  it  is  absolutely  essential. 
If  one  is  needed,  however,  use  it  for  as  short  a  period  of 
time  as  is  necessary.  In  connection  with  those  cases  in 
which  pus  has  been  flowing  from  the  line  of  fracture  for 
some  time,  it  is  a  wise  procedure  to  freshen  the  edges  of 
the  fracture  by  curettement ;  and  no  instruments  are  bet- 
ter adapted  for  this  purpose  than  the  pyorrheal  planers 
spoken  of  earlier  in  the  chapter. 

Packing  of  Wounds  in  the  Mouth 

It  is  a  well  known  fact  that  if  a  piece  of  cotton  is  placed 
in  the  socket  of  an  extracted  tooth  it  becomes  foul  in  a 


EXTERNAL  INCISIONS  225 

short  time  even  though  the  cotton  be  saturated  with  some 
antiseptic.  Therefore  cotton  should  not  be  used,  for  it  is 
entirely  unnecessary  if  one  adopts  the  following  method 
and  technique.  If  it  is  desired  to  keep  the  lips  of  the 
wound  open,  to  assist  in  free  drainage,  a  roll  of  sterilized 
rubber  dam  is  used,  which  has  previously  been  immersed 
in  camphophenic  liquid  or  some  other  equally  good  non- 
irritating  antiseptic  and  analgesic.  If  the  periosteum 
has  been  removed  from  the  bone  because  of  some  slip 
in  the  operator's  control,  there  will  very  frequently  be 
a  severe  after-pain.  (c)uite  often  there  is  severe  pain  fol- 
lowing a  simple  extraction  with  no  loss  of  bone  or  peri- 
osteum. In  these  cases  the  wound  should  not  be  packed 
with  cotton,  as  previously  stated,  but  camphophenic  and 
orthoform  should  be  used.  The  former  is  a  germicidal 
antiseptic  and  analgesic  and  comes  in  a  liquid  state.  The 
latter  is  anesthetic  and  sedative  and  is  a  white  powder. 
The  two  are  mixed  to  the  consistency  of  stiff  putty  and 
inserted  in  the  socket  or  in  the  wound  and  the  pain  will 
be  thus  controlled,  the  wound  clean  and  the  lips  of  it 
spread  apart.  Should  pus  be  flowing  from  the  wound  the 
preparations  should  be  mixed  to  a  looser  consistency  and 
applied  loosely  and  gently  in  the  cavity.  In  the  writer's 
opinion  it  far  excels  the  iodized  gauze  or  Buckley's  euro- 
form  because  the  case  is  handled  more  cleanly  and  there 
is  thus  less  irritation  to  the  tissues. 

Suturing  Bone  with  Metallic  Substances 

In  treating  of  suturing  with  a  silver  wire  or  any  metal- 
lic substance,  it  should  be  stated  that  in  practically  every 
case,  in  which  suturing  was  employed  in  a  fracture,  where 
there  could  be  invasion  of  microorganisms  into  the  line 
of  fracture  from  within  the  mouth,  the  result  was  ne- 
crosis. A  bone  would  have  no  chance  to  unite  with  many 
such  wires  acting  as  foreign  bodies  to  the  tissues  and 
cutting  off  the  blood  supply  because  the  vitality  of  the 


226     MAXILLAEY  FRACTURES  (SURGICAL) 

part  would  be  so  sapped  by  this  technique  that  necrosis 
would  surely  follow.  There  may  be  exceptions  to  the 
rule  that  suturing  through  the  jaw  bones  invariably  re- 
sults in  necrosis,  but  the  exceptions  are  few.  It  is  to  be 
used  only  when  no  other  method  may  be  employed  and 
rather  than  use  it  it  is  better  to  sacrifice  some  occlusion, 
with  a  possible  resulting  asymmetry,  rather  than  hazard 
the  train  of  evils  that  attend  and  follow  an  extensive  ne- 
crosis. 

Hemorrhage 

Factors  Inducing  Hemorrhage.— A  word  about  hemor- 
rhage and  its  control  will  be  said  here. 

Injury  to  a  vessel,  foreign  bodies,  the  spread  of  the 
infection  and  incomplete  fixation  of  the  parts  are  dom- 
inant factors  in  producing  hemorrhage.  Especially 
severe  in  these  gun-shot  wounds  is  the  hemorrhage  that 
follows  injury  to  the  lingual  artery,  but  pressure  with 
gauze  and  some  sort  of  appliance  to  hold  the  gauze 
around  and  under  the  tongue  is  an  important  means  of 
controlling  it.  In  this  connection  it  should  be  stated  that 
there  is  danger  of  the  gauze  having  been  left  in  the  mouth 
for  too  long  a  period  of  time,  thus  producing  an  infection 
which  will  be  secondary  to  the  conditions  that  caused  the 
flow7  of  blood.  As  to  the  control  of  hemorrhage,  it  is  of 
course  familiar  to  all,  hut  possibly  one  or  two  practical 
points  may  be  mentioned  which  may  prove  of  great  value. 

Treatment  of  Hemorrhage.— The  patient  should  be  di- 
rected to  make  a  mush  bite  in  modeling  compound;  the 
impressions  thus  formed  are  filled  with  light  gauze  satu- 
rated with  adrenalin;  this  modeling  compound  splint 
with  the  gauze  therein  is  inserted;  a  skull  cap  such  as 
previously  described  is  put  on  and  the  buckles  tightened. 
Thus  a  very  efficient  method  of  controlling  hemorrhage 
is  obtained.  Pressure  may  be  exerted  in  some  cases  by 
inserting  a  cork  stopper  about  which  gauze  saturated 
with  adrenalin  has  been  wround.    This  is  inserted  between 


EXTERNAL  INCISIONS  221 

the  patient's  upper  and  lower  tooth  and  he  is  directed  to 
close  his  jaws  and  use  the  skull  cap.  Calcium  lactate  is 
advocated  by  the  textbooks.  According  to  the  writer's 
experience  its  real  value  is  questionable.  The  use  of 
horse  serum  is  often  very  efficacious  and  should  be 
thought  of  in  this  connection. 

Resume  of  Foregoing  Matter 

An  attempt  has  been  made  thus  far  to  emphasize  some 
of  the  important  features  presented  in  the  diagnosis  and 
treatment  of  maxillary  fractures,  principally  those  met 
with  in  military  life.  The  importance  of  absolute  clean- 
liness as  far  as  possible  in  the  oral  cavity  has  been  given 
marked  attention.  The  spicules  of  bone  that  might  be 
lodged  in  the  soft  tissues  or  in  the  line  of  fracture,  which 
acted  as  irritating  influences,  have  been  discussed  and 
the  importance  of  iodin  has  been  considered  as  being  sec- 
ond to  none  in  completing  the  cleansing  of  the  oral  cavity. 
Gun-shot  grounds  have  been  discussed  and  it  is  known 
that  the  speed,  size,  shape  and  character  of  the  missile, 
the  angle  at  which  it  struck  the  tissues  and  the  amount 
of  tissue  dislodged  are  important  considerations  in  de- 
termining the  extent  of  the  injury  to  both  osseous  and 
soft  tissue. 

It  has  been  stated  that  a  bullet  may  enter  the  jaw  at 
a  certain  angle  and  dislodge  a  piece  of  bone,  which  piece 
of  bone  passes  with  almost  explosive  violence  through 
both  hard  and  soft  tissue  ahead  of  it,  acting  as  a  second- 
ary projectile.  It  may  readily  be  seen  then  that  the 
amount  of  injury  to  both  soft  and  hard  tissue  would  de- 
pend largely  upon  the  size,  shape  and  force  of  the  bone 
projectile,  so-called,  as  well  as  the  size,  shape,  speed, 
etc.,  of  the  missile.  This  is  very  important  to  bear  in 
mind. when  examining  wounds,  for  it  is  good  judgment 
to  determine  the  way  the  projectile  hit  the  tissues  because1 
the  extent  of  injury  done  is  thus  presented  a  little  more 


228     MAXILLARY  FRACTURES  (SURGICAL) 

clearly  than  it  otherwise  might  have  been.  Tt  is  essen- 
tial to  bear  in  mind  that  the  contraction  of  the  tissues 
on  account  of  the  injury,  the  pus  formation,  the  loss 
of  functions  of  the  jaw,  and  the  displacement  of  bone 
caused  by  unbalanced  muscular  traction,  are  the  factors 
that  make  for  the  gaping  wound  so  often  seen.  A  man 
not  familiar  with  such  conditions  might  make  a  progno- 
sis that  was  far  from  what  it  should  have  been.  The 
fact  that  all  the  tissues  in  the  mouth  are  subject  to  such 
easy  infection  with  the  anatomical  and  physiological 
balance  upset  leads  one  to  look  immediately  for  infec- 
tion after  every  such  wTound  and  to  be  on  guard  against 
such  a  possibility. 

It  has  been  shown  that  where  there  is  a  compound  frac- 
ture in  one  section  of  the  jaw  there  may  be  a  simple  frac- 
ture, with  no  break  in  the  continuity  of  the  surface,  in 
another  part  because  of  the  transmitted  force.  That  con- 
dition occurs  frequently  even  in  private  practice.  The 
diagnostician  in  cases  of  this  sort  should  have  the  pos- 
sibility of  such  a  condition  ever  present  in  his  mind  and 
make  a  thorough  examination,  mapping  out  the  lines  def- 
initely and  following  the  anatomical  areas  carefully  in 
determining  the  extent  and  number  of  fractures.  In  plas- 
tic operations  it  is  necessary  to  restore  functional  activity 
and  minimize  the  deformity.  Therefore  it  is  very  im- 
portant not  to  attempt  any  operation  of  this  character 
while  pus  is  flowing  from  wounds  in  the  mouth  and  while 
the  parts  are  not  made  immovable.  There  is  a  great  ten- 
dency for  infection  and  gaping  of  the  wounds  made  in  the 
plastic  surgery  because  of  the  pus  formation  and  the 
movements  of  the  jaws. 

Tetanus.— The  tetanus  organism  has  also  been  touched 
upon  and  mention  has  been  made  of  the  possibility  of 
latent  tetanus.  It  is  advised  that  all  become  familiar 
with  the  pathology  of  this  condition  and  its  differentia- 
tion from  trismus  of  dental  origin  and  temporomandibu- 
lar irritation,  for  the  ability  to  recognize  it  in  an  ob- 


PRACTICAL  ASPECTS  OF  TREATMENT     229 

scure  or  attenuated  form  may  be  the  means  of  saving  a 
life. 

Subjects  Discussed.— The  writer  has  also  discussed 
drooling;  insertion  of  wicks;  displacements;  fractures 
at  the  angle ;  certain  splints  and  why  they  are  used ;  dif- 
ferential diagnosis  of  fracture  at  the  neck  of  the  condyle 
and  dislocation;  a  study  of  recoil;  therapeutics;  illus- 
trations with  description  of  Cases  have  been  given  and 
the  surgical  technique  and  treatment  discussed.  The 
technique  of  conductive  anesthesia  has  been  covered  and 
possible  complications  considered  in  detail;  free  drain- 
age was  dealt  with  at  some  length.  Here  it  is  sufficient 
to  say  that  it  is  of  the  first  importance  to  establish  free 
drainage  and  to  remember  that  most  of  these  abscesses 
which  are  secondary  to  a  fracture  are  caused  by  spicules 
of  bone  and  that  confined  pus  and  irritation  from  wounds 
may  cause  the  greatest  amount  of  injury  to  the  human 
organism  because  of  absorption.  Besides  the  removal 
of  these  spicules  of  bone,  care  must  be  taken  of  roots 
of  teeth  and  tartar.  It  must  be  remembered,  however, 
that  the  extent  of  the  operation  and  the  vitality  of  the 
patient  are  important  considerations  in  determining 
whether  one  should  or  should  not  attempt  to  remove 
foreign  bodies  immediately. 

Thus  far  discussions  of  the  theoretical  and  technical 
sides  of  this  subject  have  been  covered.  The  practical 
side  of  the  question  will  now  be  touched  upon.  With  the 
assistance  of  illustrations  the  study  and  treatment  of 
some  of  these  cases  seen  by  surgeons  in  the  war  will  be 
followed. 


PRACTICAL   ASPECTS   OF  TREATMENT 

Unerupted  Malposed  Third  Molar.— The  first  illustra- 
tion shows  an  unerupted  malposed  third  molar  lying 
longitudinally  in  the  ramus,  midway  between  the  angle 


230     MAXILLARY  FRACTURES  (SURGICAL) 

and  the  joint  with  necrosis  of  bone.  This  emphasizes  the 
importance  of  always  having  a  radiograph  made  to  study 
any  diseased  condition  which  involves  the  teeth  or  the 
osseous  tissues  within  the  dental  field.  The  advantages 
of  the  radiograph  in  this  case  were  many.  It  immedi- 
ately disclosed  the  cause  of  the  pain  and  governed  the 
technique  in  operating.  It  showed  how  easily  access 
could  be  gained  to  the  tooth  from  within  the  mouth 
through  the  thin  lamina  of  bone  overlying  the  crown  of 


Fiir.  93. — Unertpted  Mai.posed  Third  Molar.  A  indicates  nialposed  third 
molar;  B  indicates  carious  bone  about  tooth.  Shows  danger  of  inviting 
fracture. 


the  tooth  at  the  anterior  border  of  the  ramus.  It  also 
indicated  the  liability  to  fracture  the  bone  through  the 
socket  of  the  tooth  if  undue  force  was  used  in  its  re- 
moval, for  the  length  of  the  tooth  from  the  crown  to  the 
apex  of  the  roots  was  almost  equal  to  the  depth  of  the 
ramus  in  an  anteroposterior  direction.  It  may  also  be 
stated  here  that  with  the  history  and  clinical  symptoms 
in  addition  to  the  radiographic  picture  it  is  fair  to  pre- 
sume, that  the  bone  was  diseased  and  that,  the  tooth  be- 
ing loose  in  its  socket,  not  much  force  would  be  required 
to  remove  it.  This  proved  to  be  the  case.  The  value 
of  the  radiograph  is  fully  demonstrated  in  this  one  case. 


PRACTICAL  ASPECTS  OF  TREATMENT     231 

In  the  study  of  all  radiographs,  conclusions  in  support 
of  clinical  evidence,  symptoms  and  history  must  be 
reached.  As  the  late  Doctor  Murphy  of  Chicago  so  well 
stated,  "A  radiograph  may  make  a  diagnosis  in  some 
cases,  but  a  radiograph  plus  the  use  of  our  cortical  cells 
makes  a  more  accurate  and  scientific  diagnosis  in  every 
case." 

Fracture  Between  Cuspid  and  First  Bicuspid.— I  re- 
call a  very  interesting  case  in  which  the  radiograph 
showed  not  only  a  fracture  between  the  cuspid  and  first 
bicuspid  on  the  lower  left  side,  but  also  the  root  of  the 
lower  left  second  bicuspid  with  radiolucent  area  (which 
was  not  to  be  seen  in  visual  examination),  and  an  im- 
pacted inferior  third  molar  on  the  same  side.  The  pic- 
ture emphasized  very  forcefully  the  real  necessity  and 
value  in  having  a  radiograph  made,  not  only  intra-orally 
but  also  extra-orally,  before  attempting  to  set  a  fracture. 
In  connection  with  this  fracture  a  supposed  case  might 
be  cited.  The  fracture  might  have  been  set  and  a  week 
afterwards  the  patient  might  have  developed  swelling 
and  pain,  either  in  the  line  of  fracture,  the  second  bi- 
cuspid area,  or  in  the  angle  region.  Had  not  the  radio- 
graph been  made  one  might  conclude  that  there  was  in- 
fection from  spicules  of  bone  in  the  line  of  fracture,  but 
with  the  radiograph,  attention  is  immediately  focused 
upon  the  possibility  of  either  the  hidden  bicuspid  root  or 
the  malposed  molar  being  the  seat  of  the  trouble.  In 
other  words, — with  the  radiograph  one  gets  a  clearer  con- 
ception of  conditions  than  one  would  otherwise  have 
had.  It  makes  for  a  more  accurate  diagnosis,  does  away 
with  unnecessary  removal  of  tissue  and  in  many  cases 
points  the  way  for  surgical  procedure.  Of  course  with 
a  radiograph  taken  before  the  fracture  was  set,  the  hid- 
den root  would  have  been  extracted  for  reasons  that 
have  been  stated  earlier. 

Quite  frequently  old  roots  that  are  lying  dormant  ap- 
parently, blaze  up  with  abscess  formation  as  an  indirect 


232     MAXILLAEY  FEACTUEES  (SUEGICAL) 

result,  it  would  seem,  of  impact  in  the  region  in  which 
they  are  situated. 

Fracture  of  Mandible.  — The  next  picture  (Figure  94) 
shows  a  case  of  fracture  of  the  mandible  as  shown  by  a 
line  between  the  lower  right  second  bicuspid  and  first 
molar  and  it  can  readily  be  seen  from  the  radiograph 


Fig.  94. — Fracture  between  the  Eight  Inferior  Second  Bicuspid  and 
First  Molar.  A  points  to  spicule  of  bone,  the  removal  of  which  was 
followed  by  absence  of  pus  formation;   B  points  to  line  of  fracture. 


that  there  seems  to  be  little  or  no  break  in  the  continuity 
of  the  inferior  border  of  the  bone.  Whether  it  is  dis- 
placed inwardly  or  outwardly  is  known  from  the  clinical 
evidence,  and  as  a  result  of  clinical  and  radiographical 
evidence  combined,  it  is  concluded  that  the  muscular 
traction  is  but  slightly  unbalanced.  Such  a  fracture  may 
be  treated  in  a  number  of  ways,  preferably  with  the 
bands  on  the  teeth  with  labial  and  lingual  bars  soldered 


PKACTICAL  ASPECTS  OF  TREATMENT     233 

thereto;  with  the  aluminum  splint  which  jackets  the 
teeth  above  the  gingival  border  or  with  the  interdental 
vulcanite  splint;  or  with  wires  ligated  about  the  necks 
of  teeth,  the  ends  of  which  have  been  twisted  and  tight- 
ened to  similar  wires  on  the  teeth  of  the  opposite 
jaw. 

Splint  of  Preference. — In  this  case  the  band  with  the 
bars  is  undoubtedly  the  best  method  in  the  treatment  of 
Figure  94,  because  it  is  the  most  clean,  because  it  gives 
an  opportunity  to  observe  and  control  occlusion,  because 
the  patient  has  some  functional  capacity  under  treat- 
ment even  though  it  be  diminished,  and  because  there  is 
absolute  fixation  of  the  parts.  This  splint  will  hold  be- 
cause there  is  little  or  no  muscular  traction  to  work  it 
from  its  anchorages.  The  aluminum  jacket  splint  might 
be  used,  but  it  is  the  second  choice  because  control  of  oc- 
clusion is  not  possible.  The  vulcanite  interdental  splint 
might  be  used  but  should  be  advised  against  because  it 
is  unclean,  because  one  cannot  study  the  occlusion,  and 
because  the  patient  has  no  use  of  the  jaws  in  the  mastica- 
tion of  semisolids.  The  wires  might  be  used,  as  described 
earlier,  but  the  use  of  them  is  not  recommended  in  this 
case  because  there  is  little  or  no  muscular  traction,  be- 
cause the  edges  of  the  fracture  can  be  easily  placed  in 
apposition,  because  the  method  is  unclean,  inviting 
chronic  gingivitis ;  and  because  mastication  of  substances 
is  impossible.  Relative  to  the  interdental  splint,  it  may 
be  said  that  it  is  now  used  only  in  cases  where  a  number 
of  teeth  are  missing,  where  there  is  great  muscular  trac- 
tion, or  where  there  is  loss  of  osseous  tissue.  The  ful- 
crum to  assist  in  fixation  of  the  parts  with  the  interdental 
vulcanite  splint  is  the  skull,  by  means  of  the  skull  cap 
previously  mentioned  or  some  modification  of  it.  In  all 
cases,  especially  for  the  first  few  days,  a  skull  cap  is  used 
at  night  on  account  of  the  tendency  of  the  patient  to  open 
the  mouth  while  asleep  and  in  this  way  work  the  splint 
from  the  teeth. 


2.34     MAXILLARY  FRACTURES  (SURGICAL) 

Fracture  Between  First  and  Third  Molars,  Second 
Molar  Missing".— Figure  95  illustrates  a  fracture  in  the 
body  of  the  bone  just  anterior  to  the  mesial  surface  of 
the  third  molar  with  spicules  of  bone  in  the  line  of  frac- 
ture, the  removal  of  which  is  absolutely  necessary  to 
stem  the  flow  of  pus. 

hi  the  study  of  the  picture  we  are  impressed  very 
forcefully  with  the  importance  of  retaining  this  third 


Fig.  95. — Fracture  of  the  Body  of  the  Bone  between  First  and  Third 
Inferior  Molars  with  the  Second  Molar  Missing.  Showing  the 
importance  of  saving  teeth  to  maintain  fixation  and  preserve  symmetry  of 
the  face.   A  and  B  indicate  spicules  of  bone;  C  indicates  line  of  fracture. 

molar,  for  if  we  removed  it  the  approximation  and  fixa- 
tion of  the  distal  fragment  of  the  fracture  to  the  an- 
terior fragment  would  not  be  under  positive  control  and 
therefore  an  asymmetry  of  the  face  would  be  invited 
after  union  had  taken  place.  Had  we  removed  this  tooth 
it  would  not  have  been  possible  to  control  this  distal 
fragment  with  that  degree  of  scientific  accuracy  which 
would  be  possible  with  the  tooth  in  place  and  we  might 
have  an  outward  or  an  inward  displacement  of  the  ramus 


PRACTICAL  ASPECTS  OF  TEEATMENT     235 

with  the  consequent  asymmetry  of  the  face,  although  our 
occlusion  might  be  fairly  perfect.  The  retention  of  this 
tooth  also  made  it  possible  to  use  the  angle  bands  with 
wires  to  maintain  fixation  after  the  spicules  of  bone  had 
been  removed  with  pyorrheal  planers  and  the  parts  thor- 
oughly cleansed. 

Fracture  in  which  Vulcanite  Interdental  Splint  is  Used. 
—It  is  necessary  in  the  treatment  of  a  case  such  as 
shown  in  Figure  96  to  use  the  interdental  vulcanite  splint. 
Since  we  have  no  tooth  in  the  distal  fragment  in  this  case 
it  is  necessary  in  reducing  the  fracture  on  our  plaster 
model  to  be  guided  in  bringing  about  proper  relations  by 
studying  the  direction,  extent  and  amount  of  displace- 
ment and  the  muscular  traction  exerted. 

Having  approximated  the  fragments  on  the  model  as 
nearly  correctly  as  our  judgment  directs  us,  a  vulcanite 
interdental  splint  is  made  and  inserted.  Lateral  and 
anteroposterior  radiographs  are  now  made  with  the  splint 
in  position,  to  show  how  nearly  correctly  the  fragments 
are  in  apposition.  If  they  are  not  in  proper  relation 
warm  modeling  compound  is  placed  in  the  vulcanite  splint 
at  the  proper  place  to  exert  pressure  in  a  direction  which 
will  bring  about  the  desired  apposition.  The  splint,  with 
the  modeling  compound  attached,  is  inserted  and  radio- 
graphs are  again  made  to  learn  if  the  parts  are  in  cor- 
rect anatomical  relation.  If  they  are  not,  this  process 
is  repeated  until  the  desired  apposition  is  brought  about. 
When  we  have  this  approximation  satisfactorily  ad- 
justed, the  modeling  compound  is  replaced  with  vulcanite 
in  the  usual  manner  and  the  jaw  finally  set,  with  the  skull 
cap  in  position  to  assist  in  maintaining  fixation. 

Reduction  and  Fixation  by  Wiring  the  Teeth.— The 
method  of  reducing  a  fracture  and  maintaining  fixation 
by  wires  consists  in  simply  wiring  the  teeth  of  one  jaw  to 
those  of  the  opposite  jaw.  It  is  sufficient  in  the  bicuspid 
or  molar  regions  to  wire  one  tooth  in  the  upper  jaw  to 
the  corresponding  tooth  of  the  lower  jaw.     In  the  in- 


236     MAXTLLARY   FRACTURES  (SURGICAL) 

cisor  region,  however,  it  is  better  to  wire  two  teeth  in  the 
upper  jaw  to  two  teeth  of  the  lower  jaw.  This  method 
has  the  advantage  of  easy  adaptation,  but  if  continued 
until  union  has  taken  place,  without  constant  super- 
vision, might  cause  a  gingivitis  that  might  terminate 
in  extensive  destruction  to  the  dental  organs  and  bone. 


Fig.  90. — Fracture  of  the  Body  of  the  i^one  with  Considerable  Dis- 
placement and  no  Tooth  in  the  Distal  Fragment. 

It  is  a  very  efficient  and  simple  method  of  reducing  the 
fragments  and  maintaining  fixation  and  in  many  cases 
it  is  quite  invaluable,  but  in  most  cases  is  to  be  used  only 
as  a  temporary  treatment. 

The  latter  part  of  this  chapter  is  aimed  to  cover  the 
subject  of  splints  and  their  adaptations  to  different  cases, 
even  those  in  which  there  is  an  immense  amount  of  de- 
struction of  the  tissues.  The  splints  described,  with  modi- 
fications of  them,  are  the  only  ones  that  have  been  used 


PRACTICAL  ASPECTS  OF  TREATMENT     237 

up  to  the  present  time  in  the  work  in  the  war  zone. 
Conclusions.  — The  chief  points  to  be  remembered  in  a 
given  case  are  to  get  at  the  fracture  early,  to  cleanse  the 
mouth  and  wound  well  and  preserve  this  cleanliness,  to 
remove  the  spicules  of  bone,  to  reduce  the  fragments, 
to  maintain  fixation,  and  to  watch  the  occlusion. 


CHAPTER  VIII 

EXTRACTION  OF  TEETH 

Byron  II.  Strout 

As  a  preliminary  it  may  be  supposed  that  it  has  been 
decided  that  a  certain  tooth  or  teeth  must  be  removed. 
There  are  of  course  many  conditions  which  may  cause 
an  operator  to  reach  this  conclusion,  and  perhaps  it  will 
be  well  at  the  outset  to  catalogue  some  of  the  reasons  for 
extraction. 

EXTRACTIONS  OF  THE  PERMANENT  TEETH 

Reasons  foe  Exteaction 

Pyorrhea.— All  teeth  are  to  be  extracted  that  are  so 
loosened  by  pyorrhea  or  other  disease  that  usefulness 
is  at  an  end,  provided  no  hope  of  cure  remains. 

Insecure  Roots. — All  roots  or  portions  of  teeth  not  suf- 
ficiently solid  to  support  crowns  should  be  removed. 

Roots  with  Apical  Abscess.— All  roots  which,  though 
solidly  placed,  and  firm  in  their  sockets,  are  still  hope- 
lessly affected  by  apical  abscess  should  be  eliminated. 

Incurable  Apical  Abscess. — Any  tooth,  no  matter  how 
firmly  fixed,  how  good  or  how  useful,  which  has  an  incur- 
able apical  abscess,  with  or  without  a  fistulous  opening, 
should  be  reckoned  a  candidate  for  the  forceps. 

Supernumerary  Teeth.  —  Supernumerary  and  mis- 
placed teeth  in  many  cases  will  require  extraction.  In 
this  class  will  be  found  many  of  the  most  difficult  extrac- 
tions.    Some  of  these  cases,  notably  unerupted  and  im- 

238 


EXAMINATION  OF  THE  MOUTH  239 

pacted  third  molars,  will  tax  to  the  utmost  the  skill  of 
the  surgeon. 

Sound  but  Useless  Teeth.— Extraction  of  sound  teeth 
may  be  required  in  preparing  mouths  for  artificial  sub- 
stitutes in  those  cases  where,  from  carelessness,  disease 
or  malpractice,  so  many  teeth  have  been  lost  or  destroyed 
as  to  make  the  retention  of  the  remainder  worse  than 
useless. 

These  classes  as  they  have  been  enumerated  will  in- 
clude practically  all  conditions  in  army  practice  where 
extraction  is  necessary  or  advisable. 


EXAMINATION   OF  THE  MOUTH 

A  decision  that  extraction  is  necessary  having  been 
made,  it  is  imperative  before  proceeding  with  the  actual 
operation  that  a  careful  and  thorough  examination  of 
the  mouth  and  of  the  tooth  or  teeth  involved  be  made. 

Examination  of  Tooth  Structure.— The  examination  of 
the  tooth  should  determine  the  amount  of  substance 
present,  and  its  condition,  whether  firm  and  solid,  or 
softened  by  decay.  It  should  be  noted  whether  the 
tooth  substance  is  destroyed  below  the  margin  of  the 
gum,  and  if  so,  how  far  below  that  margin.  A  special 
examination  must  be  made  of  the  central  portion  of 
badly  decayed  teeth  to  determine  how  solid  a  shell  may 
be  remaining.  Often  upon  the  result  of  such  an  exam- 
ination depends  the  selection  of  the  proper  instruments 
for  the  performance  of  the  successful  operation. 

If  many,  or  any,  perfect  teeth  remain  in  place,  their 
shape  must  be  noticed,  especially  as  to  whether  they  are 
short  and  thick  or  long  and  slender;  the  rule  being  that 
short,  thick  teeth  are  firmly  planted  in  a  solid  alveolar 
process,  while  long  and  slender  teeth  as  a  rule  are  less 
firmly  seated  in  an  alveolar  process  of  much  less  solid 
structure. 


240  EXTRACTION  OF  TEETH 

Examination  of  Alveolar  Process.— The  structure,  size, 
etc.,  of  the  alveolar  process  must  be  examined  to  deter- 
mine whether  it  be  thick  or  thin,  high,  or  low  and  flat.  It 
should  be  noted  whether  the  teeth  stand  alone  supported 
by  solid  bone  all  about,  or  if  they  are  in  normal  appo- 
sition to  each  other,  supported  mesially  and  distally  only 
by  thin  laminae  of  bone.  This  examination  may  aid  in  de- 
termining the  direction  for  the  application  of  the  neces- 
sary force,  and  oftentimes  may  aid  in  forming  a  judg- 
ment as  to  the  amount  of  force  likely  to  be  required. 

Condition  of  Gums.— The  condition  of  the  gum  and  tis- 
sues about  or  near  the  teeth  should  be  noticed.  It  is 
essential  to  see  whether  the  tissue  appears  of  normal 
pink  color  and  of  firm  consistency,  or  pale  and  flabby, 
or  if  it  is  dark  and  purplish  and  congested  with  blood. 
It  must  be  noticed  whether  or  not  there  is  an  inflamma- 
tory process  present.  A  normal  gum  shows  that  no  spe- 
cial precautions  need  be  taken.  A  pale  and  flabby  gum 
may  indicate  a  lowered  general  vitality,  with  possible 
tendency  to  severe,  or  even  excessive  hemorrhage  after 
operation.  A  turgid  or  purple  appearance  may  indicate 
deep-seated  trouble,  as  necrosis  of  bone  near  or  about 
the  tooth  to  be  extracted,  requiring  extra  precautions  to 
be  taken  as  to  asepsis  and  after  treatment.  Any  in- 
flammatory process  present  in  or  near  the  operative  field 
requires  that  special  aseptic  care  be  .taken,  especially 
if  any  injection  or  wound  other  than  that  made  by  the 
extraction  be  required. 


INSTRUMENTATION 

All  these  points  having  been  carefully  noted,  one  is 
ready  to  proceed  to  the  selection  of  the  proper  instru- 
ments wTith  which  to  perform  the  operation. 

To  describe  in  detail  the  numberless  forms  of  forceps 
to  be  found  on  sale  at  the  present  time  would  be  mani- 


INSTRUMENTATION  241 

festly  impossible.  It  will  suffice  to  describe  the  essential 
forms  of  forceps  required,  and  then  to  point  out  those 
which  have  in  the  writer's  experience  been  found  to  be 
most  desirable. 

Types  of  Foeceps 

Beaks 

The  first  part  of  the  forcep  to  be  noticed  is  the  beak, 
or  grasping  portion. 

Types  of  Teeth.  — There  are  roughly  three  forms  of 
teeth  requiring  extraction:  (a)-  Single-rooted,  as  the 
incisors,  cuspids,  and  bicuspids;  (b)  two-rooted,  with 
the  roots  mesio-distally  placed  (the  lower  molars) ;  and 
(c)  three-rooted,  with  two  buccal  and  one  lingual  root 
(the  upper  molars).  There  are  also  two  classes  in  which 
the  relative  position  of  crown  and  root  are  reversed, 
upper  and  lower  teeth. 

Forms  of  Beaks.— Obviously  then,  there  must  be  for- 
ceps with  beaks  shaped  to  grasp  single-rooted  teeth,  and 
these  must  be  made  in  two  general  forms,  for  upper  and 
lower  teeth.  There  must  be  forceps  with  beaks  formed 
to  grasp  the  two-rooted  molars;  these  are  all  found  in 
the  lower  jaw.  There  must  also  be  forceps  with  beaks 
fitted  to  the  three-rooted  molars;  these  molars  are  all 
found  in  the  upper  jaw,  but  occur  on  right  and  left  sides ; 
therefore  it  will  be  necessary  that  the  beaks  of  these 
forceps  be  made  in  pairs. 

A  set  of  forceps,  then,  for  extracting  teeth  of  ordinary 
forms  must  include  one  for  lower  incisors  and  bicuspids, 
one  for  upper  incisors  and  bicuspids,  one  for  lower  mo- 
lars, and  two,  right  and  left,  for  upper  molars,  making 
five  pairs  in  all.     These  five  are  absolute  necessities. 

Special  Forceps  Required. — Experience  has  shown 
that  one  meets  with  many  small,  single-rooted  teeth,  also 
small  roots  of  multirooted  teeth.  For  these  are  required 
narrow-beaked  or  so-called  root  forceps  for  both  upper 
and  lower  jaws.    It  has  also  been  found  that  many  upper 


242  EXTRACTION  OF  TEETH 

third  molars  are  not  normally  placed,  and  frequently  are 
abnormally  formed,  as  well  as  some  second  molars.  For 
these  are  required  a  third  pair  of  upper  molar  forceps, 
with  differently  formed  beaks,  placed  upon  the  handles 
at  a  different  angle.  These  will  add  three  pairs  to  the 
set,  making  eight  pairs  in  all. 

Beaks  of  Special  Width. — Again,  it  is  frequently 
found  that  there  are  anterior  teeth  much  crowded,  and 
with  one  or  more  forced  out  of  line.  Such  teeth  are  of 
ordinary  size,  and  are  firmly  fixed  in  the  alveolar  process, 
but  overlapped  by  other  teeth  in  such  a  way  as  to  pre- 
clude the  possibility  of  using  forceps  of  ordinary  width. 
For  such  cases  the  so-called  hawk-bill  forceps  have  been 
designed.  The  beaks  are  narrow  as  those  of  the  small 
root  forceps,  but  additional  strength  has  been  provided 
by  greatly  thickening  them.  Very  useful  also  are  those 
forceps  designed  for  badly  broken  down  teeth  and  roots, 
with  beaks  of  the  same  width  as  the  ordinary  incisor 
forceps,  but  with  the  ends  rounded  and  sharpened.  Such 
forceps  are  called  alveolar  forceps,  because  of  the  ease 
with  which  the  beaks  may  be  forced  between  the  tooth 
and  the  process. 

Handles 

Shape  of  Handles.— Next  in  importance  to  the  shape  of 
the  beaks  is  that  of  the  handles.  These  should  be  so 
formed  as  to  afford  an  easy  and  firm  grasp  for  the  hand, 
long  enough  to  give  sufficient  leverage  that  force  may 
be  easily  applied  to  the  tooth,  and  so  roughened  that  the 
hand  will  not  easily  slip  upon  them.  In  many  patterns 
of  forceps  the  handles  are  so  short  that  extreme  strength 
is  required  to  dislodge  a  firmly  fixed  tooth. 

The  handles  should  be  as  nearly  straight  as  possible. 
Many  patterns  have  one  of  the  handles  formed  with  a 
crook  intended  to  engage  one  or  more  of  the  fingers.  At 
the  present  time,  however,  most  operators  agree  that 
such  crooks  are  rather  a  detriment  than  a  help. 


INSTRUMENTATION  243 

Joint  of  Handle. — The  joint  should  be  as  strong  as 
possible,  as  it  is  required  to  withstand  a  terrific  strain. 
The  older  models  have  the  joint  finished  in  an  octagon 
shape.  Most  modern  patterns  are  oval,  all  angles  being 
carefully  rounded  for  the  purpose  of  avoiding  as  much 
as  possible  the  danger  of  injury  to  the  lips  and  cheek  of 
the  patient. 

Pivot  of  Handle. — The  pivot  itself  or  fulcrum  of  the 
lever  should  be  as  near  the  beak  as  possible.  The  nearer 
the  pivot  is  placed  to  the  grasping  portion  of  the  beak 
the  more  power.  Where  the  joint  comes  together  in  the 
act  of  closing  the  forceps,  the  edges  should  be  rounded 
over  to  help  in  avoiding  pinching  of  tissue  in  the  joint. 

Various  Instruments 

Other  instruments  required  in  the  operating  kit  of  the 
extracting  surgeon  will  be  mirrors,  dressing  forceps,  or, 
as  dentists  usually  call  them,  pliers,  explorers,  several 
stout,  short-bladed  hatchet  excavators  of  various  angles, 
and  elevators. 

Elevators 

In  common  use  are  three  forms  of  elevators :  straight, 
right-angled,  and  obtuse. 

Straight  Elevators.— The  straight  elevator  is  a  simple 
stout  blade,  concaved  on  one  side,  convex  on  the  other, 
the  end  rounded  and  sharp-edged,  the  whole  somewhat 
spoon-shaped.  The  handle  should  be  of  metal  to  with- 
stand sterilizing  by  boiling,  and  large  enough  that  it 
may  be  firmly  grasped.  This  instrument  is  used  mainly 
for  removing  badly  broken-down  roots  in  the  anterior 
portion  of  the  mouth. 

Right- Angle  or  Coolidge  Elevator.— The  right-angle 
elevator  should  have  a  metal  handle  of  ample  size,  a  short, 
stout  shank,  and  a  blade  approximately  three-eighths  of 
an  inch  in  length,  projecting  at  nearly,  though  not  ex- 
actly a  right  angle  from  the  shank. 


244  EXTRACTION  OP  TEETH 

Blades. — There  are  many  variations  in  the  shape  of  the 
blade.  The  form  which  most  find  useful  is  curved  slightly 
in  its  length,  the  convex  side  of  the  blade  also  rounded 
in  its  width,  ending  in  a  sharp-edged  rounded  end.  The 
inner  side  is  somewhat  concave  in  both  directions.  Some 
patterns  of  this  form  of  elevator  are  made  in  pairs,  a 
separate  instrument  for  right  and  for  left.  It  has  been 
found  more  practical  to  combine  the  two  in  one,  both 
blades  being  mounted  on  opposite  sides  of  the  one  shaft. 
Thus  the  instrument  needs  only  to  be  turned  in  the 
hand  to  be  available  for  either  side.  It  is  important  that 
the  convexities  of  the  instrument  be  smoothly  rounded, 
and  that  the  edges  be  sharp.  The  blade  should  be  made 
as  thin  as  possible,  and  still  retain  sufficient  strength 
to  sustain  the  very  heavy  strain  often  put  upon  it.  This 
pattern  is  known  as  the  Coolidge,  from  Professor  J.  B. 
Coolidge,  the  designer. 

Obtuse- Angle  Elevator.— The  obtuse-angle,  third  molar, 
or  lower  wisdom  elevator,  should  have,  like  the  others, 
a  metal  handle,  and  a  short,  stout  shank.  The  handle 
must  be  large  enough  to  afford  a  firm  grasp  for  the 
hand.  The  blade  in  this  instrument  extends  from 
the  shaft  at  an  angle  of  forty-five  degrees.  The  blade 
should  be  about  three-eighths  of  an  inch  in  length,  with 
a  width  of  three-sixteenths  of  an  inch  at  the  widest  part, 
tapering  to  a  point.  The  outer  surface  should  be  per- 
fectly flat,  the  inner  convex,  thickest  at  the  widest  por- 
tion, running  to  nothing  at  the  point.  The  edges  should 
be  sharp.  This  elevator  is  practically  solely  used  for  the 
removal  of  lower  or  third  molars. 

The  mode  of  using  the  various  instruments  will  be 
spoken  of  fully  when  describing  the  extraction  of  the 
teeth  to  which  they  are  adapted. 


OPERATIVE  PROCEDURE  245 

OPERATIVE  PROCEDURE 

Anatomy  of  Jaws.— In  the  upper  jaw  on  the  buccal 
and  labial  sides  of  the  teeth  the  process  is  thin,  these 
sides  being  nearly  vertical.  On  the  lingual  side  the  proc- 
ess is  much  thicker,  the  bone  curving  away  from  the 
teeth  in  a  concave  line  toward  the  center  of  the  palate. 

In  the  lower  jaw  the  reverse  is  the  case,  the  inner  plate 
being  vertical  and  thin,  while  the  outer  plate  is  thick  and 
heavy.  The  bone  is  thickest  opposite  the  molars,  grad- 
ually thinning  towards  the  anterior  portion  of  the  mouth, 
until  about  the  lower  incisors  the  bone  is  of  about  the 
same  thickness  labially  as  lingually. 

These  anatomical  facts  must  be  kept  in  mind  when 
applying  force  to  a  tooth  for  the  purpose  of  its  removal. 

Position  of  Operator 

A  proper  position  of  the  operator  in  relation  to  the 
patient  adds  greatly  to  the  ease  and  certainty  with  which 
the  operation  may  be  performed.  The  position  varies 
as  the  tooth  to  be  removed  is  situated  in  the  upper  or 
lower  jaw ;  also  according  to  the  style  of  instrument  used 
for  the  operation. 

Generally  in  extracting  upper  teeth  the  operator's  po- 
sition should  be  to  the  right  of,  and  slightly  in  front  of 
the  patient.  This  is  supposing  the  operator  to  be  right- 
handed.  If  left-handed,  reverse  the  positions  as  to  right 
and  left. 

The  Chair.— The  chair  should  be  elevated  to  bring  the 
patient's  head  about  on  a  level  with  the  shoulder  of  the 
operator,  and  slightly  tipped  backward.  The  left  arm 
and  hand  should  be  back  of,  or  above  the  patient 's  head, 
and  the  fingers  of  the  left  hand  engaged  in  holding  the 
lips  and  cheek  of  the  patient,  so  that  a  clear  view  of 
the  tooth  to  be  removed  may  be  obtained  (Fig.  97). 


246 


EXTRACTION  OF  TEETH 


Operator  and  Patient.  In  extracting  lower  teeth  the 
operator  should  stand  behind  the  patient,  and  slightly 
to  the  side  of  the  tooth  to  he  operated  upon.  The  chair 
should  be  lowered  to  the  fullest  extent,  and  tipped  well 
back.  As  in  operating  upon  the  upper  teeth,  the  left 
hand  holds  the  lips  and  cheek  away,  while  the  right  wields 


Fig.  97. — Position  for  Upper  Extraction7. 


the  forceps.     This  description  applies  when  using  for- 
ceps of  the  Coolidge  pattern. 

If,  as  many  do,  one  should  use  forceps,  the  beaks  of 
which  are  turned  at  a  right  angle  with  the  line  of  the 
handles,  then  the  operator  would  stand  in  front  instead 
of  behind  the  patient,  the  chair  low,  but  erect,  the  chin 
and  jaw  of  the  patient  grasped  in  the  left  hand  and  the 
right  holding  the  instrument  (Fig.  98). 


OPERATIVE  PROCEDURE  247 

Hand  Grasp.— The  proper  hand  grasp  of  the  instru- 
ment is  a  matter  in  which  there  is  more  or  less  difference 
of  opinion.  It  is  probable  that  the  conformation  of  the 
operator's  hand  may  have  a  good  deal  to  do  with  his 
method  of  grasping  the  forceps.  The  hand-grasp,  for 
most  operators,  for  the  upper  forceps  is  as  follows:  (a) 


Fig.  98.— Position  for  Lower  Extraction-. 

the  forceps  should  be  laid  with  the  angle  of  the  bayonet 
turned  upward,  diagonally  across  the  palm  of  the  open 
hand,  the  handles  resting  near  the  base  of  th6  palm  op- 
posite the  thumb,  the  upper  portion  of  the  handles  cross- 
ing the  tip  of  the  forefinger;  (b)  without  moving  the 
fingers,  the  thumb  is  closed  over  one  handle  of  the  for- 
ceps, in  such  a  way  as  to  hold  the  forceps  firmly;   (c) 


248 


EXTRACTION  OF  TEETH 


placing  the  tip  of  the  forefinger  inside  the  handle  near 
the  joint,  the  tips  of  the  other  ringers  are  allowed  to 
lightly  grasp  the  outside  of  the  same  handle.  In  this  way 
the  thumb  holds  one  beak  of  the  forceps  immovable.  The 
tip  of  the  forefinger  acts  as  a  wedge  or  spring  to  open 
the  beaks  to  the  desired  degree,  while  the  other  fingers 
act  to  close  them.     The  mutual  action  of  all  the  fingers 


4S 

¥/' 

^Bf^Jr^    M 

w 

Sfl  H?     mP 

'hi 

H 

■ 

^^^H 

Fig.  99. — Palm  View,  Handgrasp,  Upper  Forceps. 

allows  the  beaks  to  be  opened  to  the  proper  distance  and 
there  immovably  held  (Figs.  99  and  100). 

When  the  instrument  is  properly  grasped,  a  slight  turn 
of  the  wrist  forward  brings  it  into  proper  position  for 
operation  upon  any  upper  tooth. 

In  the  more  common  method  of  grasping  the  forceps, 
the  instrument  is  laid  across  the  palm  of  the  hand  less 
diagonally,  more  at  a  right  angle  with  the  fingers,  rest- 
ing more  on  the  base  of  the  fingers  than  on  the  palm,  the 
bayonet  projecting  dowmward  instead  of  upward.  The 
end  of  the  thumb  is  placed  against  the  inner  side  of  the 
outer  handle,  while  the  ends  of  the  fingers  grasp  the 


OPERATIVE  PROCEDURE 


249 


outer  side.     In  this  method  the  pressure  of  the  thumb 
governs  the  amount  of  the  opening  of  the  beaks. 


Fig.  100. — Dorsal  View,  Haxdgrasp,  Upper  Forceps. 

The  first  method  seems  to  be  better,  for  the  reason  that 
it  gives  a  more  positive  power  of  governing  the  opening 


Fig.  101. — Haxdgrasp,  Lower  Forceps. 

of  the  beaks,  but  more  especially  because  of  the  better 
position  of  the  wrist  joint,  forearm  and  elbow  during  the 


250  EXTEACTION  OF  TEETH 

operation.  In  the  first  method  the  lines  of  force  are 
nearly  straight,  while  in  the  second  the  wrist  is  turned 
at  an  awkward  angle. 

The  position  or  grasp  of  the  hand  in  using  the  lower 
forcep  is  exactly  the  same  as  the  second  method  of  grasp- 
ing the  upper  (Fig.  101). 

Stages  of  Extraction  Technic 

In  the  actual  operation  of  extraction  there  are  three 
stages  to  be  borne  in  mind:  (a)  the  seizing  of  the  tooth 
between  the  beaks  of  the  forceps;  (b)  the  loosening  of 
the  tooth  in  its  socket;  (c)  its  final  removal  from  the  jawT. 

The  Preliminary  Stage 

Choice  of  Surface. — First  one  blade  or  beak  of  the  for- 
ceps, the  handles  being  held  by  the  proper  hand  grasp,  is 
placed  upon  one  side  or  face  of  the  tooth  to  be  extracted, 
being  governed  by  the  condition  of  the  tooth,  in  the  selec- 
tion of  the  side  or  face  of  the  tooth  to  be  used  as  a  guide. 
Naturally  the  surface  which  most  nearly  approaches  an 
undamaged  condition  will  be  the  surface  selected.  Next, 
the  other,  or  as  it  may  be  called,  the  movable  beak  is 
closed  upon  the  tooth  until  it  very  nearly  touches  the 
opposite  surface. 

Grasping  the  Tooth.— The  forceps  are  placed  upon  the 
tooth  firmly  and  exactly.  There  should  be  little  waver- 
ing or  hesitancy  at  this  stage.  Every  false  motion  causes 
added  and  unnecessary  pain,  and,  in  the  case  of  timid 
patients,  may  cause  them  to  lose  courage  altogether. 

With  strong  pressure  the  edges  of  the  beaks  are  then 
forced  between  the  gum  margin  and  the  tooth  as  deeply 
as  possible,  being  careful  all  the  time  that  the  beaks  are 
not  forced  together  so  as  at  any  time  to  grasp  the  tooth. 
During  this  part  of  the  operation  the  necessity  for  a 
proper  hand-grasp  becomes  very  evident.    The  tendency 


OPERATIVE  PROCEDURE  251 

is,  as  pressure  is  applied  in  trying  to  force  the  beaks  up- 
ward or  downward,  as  the  tooth  is  situated  in  the  upper 
or  lower  jaw,  to  also  press  the  handles  together,  thus 
grasping  the  tooth  and  thereby  defeating  the  effort  made 
to  get  the  beaks  into  proper  position. 

When  the  beaks  have  been  forced  as  high  upon  the  root 
of  the  tooth  as  possible,  then,  and  not  until  then,  the 
handles  are  closed  firmly,  so  as  to  bring  the  beaks  into 
intimate  approximation  to  the  tooth.  It  should  be  re- 
membered that  there  is  no  danger  of  forcing  the  beaks 
too  high  upon  the  root. 

Sufficient  pressure  should  now  be  applied  upon  the  han- 
dles to  insure  that  the  tooth  be  so  held  by  the  beaks  as 
to  make  the  tooth  and  the  forceps  one  solid  whole;  the 
idea  being  that  any  force  applied  to  the  handles  shall 
immediately  be  communicated  to  the  tooth,  with  abso- 
lutely no  lost  motion  such  as  would  be  caused  by  the  beaks 
slipping  upon  the  tooth,  or  by  the  opening  of  the  joint 
of  the  forceps  from  the  pressure  applied.  When  the 
forceps  have  been  properly  applied  and  the  proper 
amount  of  pressure  brought  to  bear  upon  the  handles, 
one  is  ready  to  proceed  with  the  second  step,  which  is  the 
loosening  of  the  tooth  in  its  socket. 

Loosening  the  Tooth.— This  loosening  of  the  tooth  is 
a  very  important  part  of  the  operation.  It  is  to  be  re- 
membered that  in  many  cases  the  teeth  are  so  firmly 
seated  in  their  sockets  that  direct  force  will  often  fail 
to  dislodge  them.  Many  teeth  which  in  the  service  of  a 
skilled  operator  seem  very  easy  of  removal,  would  resist 
the  utmost  effort  of  a  strong  man,  if  the  force  be  ap- 
plied directly  without  previous  loosening.  The  methods 
to  be  used  in  loosening  the  teeth  vary  according  to  the 
kind  of  tooth,  and  its  position  in  the  mouth.  The  proper 
method  or  manner  of  applying  force  suitable  for  each 
tooth  will  be  spoken  of  in  detail  later.  No  jerky  motions 
are  ever  allowable.  Whatever  force  is  applied  to  the 
tooth  should  be  gradual,  and  always  under  the  full  con- 


252  EXTRACTION  OF  TEETH 

trol  of  the  operator.  More  failures  in  extraction  are 
made  by  trying  to  jerk  out  a  tooth  than  in  any  other  way. 

The  tooth  having  been  loosened,  the  final  step  in  the 
operation,  namely,  removal,  is  to  be  taken.  The  method 
of  doing  this  is  obvious. 

Removal. — Our  detailed  description  of  the  operation 
will  be  commenced  with  the  teeth  which  are  usually  eas- 
iest of  removal,  the  incisors,  upper  and  lower. 

Of  Incisors. — The  upper  central  incisors  are  usually 
quite  easily  loosened.  The  cross  section  of  this  tooth  at 
the  neck  is  somewhat  triangular,  with  the  angles  rounded. 
As  the  apex  of  the  root  is  approached  the  section  be- 
comes more  and  more  that  of  a  cylinder. 

The  proper  forcep  for  this  tooth  has  beaks  about  as 
wide  as  the  average  diameter  of  the  root  at  the  neck  of 
the  tooth.  Each  beak  is  concaved,  the  inner  on  the  arc 
of  a  smaller  circle  than  the  outer,  so  as  approximately 
to  fit  the  circumference  of  the  tooth  at  the  neck.  One 
may  use  a  pair  of  forceps  either  straight  or  bayonet- 
shaped.  For  very  solidly  placed  incisors  the  straight 
instrument  is  preferable,  but  the  type  of  forceps  usually 
used  is  the  bayonet,  as  this  form  is  applicable  to  a  much 
greater  number  of  teeth  than  the  straight  form.  The  in- 
strument is  applied  to  the  tooth  as  high  as  possible  in  the 
manner  previously  described,  and  the  tooth  grasped 
firmly. 

Force  is  now  applied  to  the  forceps  in  a  direction  tend- 
ing to  rotate  the  tooth  in  its  socket.  This  force  is  to  be 
applied  gradually,  but  firmly  and  decidedly,  and  never 
with  any  jerky  motion.  The  tooth  will  usually  start  at 
the  first  application  of  force,  but  if,  after  reasonable 
pressure  has  been  exerted  in  one  direction,  with  no  re- 
sulting movement  of  the  tooth,  the  direction  of  the  pres- 
sure should  be  reversed.  If  the  tooth  still  remains  firmly 
fixed,  these  alternations  of  direction  of  force  should  be 
made  several  times.  If  yet  unsuccessful  the  direction 
may  be  changed,  using  pressure  tending  to  tip  the  tooth 


OPERATIVE  PROCEDURE  253 

somewhat  toward  the  lip,  wTith  the  object  in  view  of 
breaking  the  thin  anterior  wall  of  the  process. 

It  must  be  remembered  that  during  all  this  applica- 
tion of  force  the  object  sought  to  be  attained  is  the  loos- 
ening of  the  tooth  in  its  socket,  and  not  its  removal; 
therefore  there  should  be  no  force  exerted  in  the  direc- 
tion of  the  long  axis  of  the  tooth  until  by  the  movements 
described  it  has  first  been  loosened.  The  amount  of  force 
which  may  be  safely  applied  to  a  tooth  in  this  manner 
without  danger  of  fracture,  varies  greatly  in  individual 
cases.  There  is  no  rule  that  will  tell  when  the  limit  of 
safety  is  reached,  but  experience  will  gradually  teach  the 
hand,  so  that  by  the  feeling  one  may  nearly  always  be 
warned  before  the  limit  is  reached. 

Of  Laterals. — The  upper  lateral  is  to  be  removed  in 
the  same  manner  as  the  upper  central.  The  same  for- 
ceps are  usually  used,  though  often  it  may  be  well  to  sub- 
stitute a  pair  having  narrower  beaks,  on  account  of  the 
average  smaller  size  of  the  tooth.  It  must  be  borne  in 
mind  that  the  lateral  is  a  much  more  slender  tooth,  that 
its  root  is  apt  to  depart  more  from  the  circular  cross 
section,  and  is  also  more  likely  to  be  crooked  in  its  length 
than  is  the  central  incisor,  therefore  more  caution  is  re- 
quired in  applying  rotary  force  for  the  loosening  of  the 
tooth.  A  change  from  rotary  to  rocking  motion  will 
more  often  be  necessary. 

The  forcep  for  the  lower  centrals  and  laterals  is  that 
known  as  the  lower  bicuspid,  though  it  is  often  advisable 
to  select  one  of  the  same  general  shape,  but  having  beaks 
of  less  width.  The  beaks  are  concaved  as  in  correspond- 
ing upper  forceps.  The  concavity  is,  however,  nearly  the 
same  in  both  beaks. 

The  lower  incisors,  centrals  and  laterals,  are  much 
flattened  at  their  necks,  and  also,  to  a  greater  or  less 
degree  throughout  the  whole  length  of  the  root,  in  the 
direction  from  mesial  to  distal.  This  flattened  form  of 
the  root  section  makes  impossible  any  rotary  motion  for 


254  EXTRACTION  OF  TEETH 

the  loosening  of  these  teeth.  Fortunately  the  alveolar 
process,  both  labially  and  lingually,  is  thin  and  easily 
broken.  The  loosening  movement,  then,  is  a  rocking 
movement,  from  lingual  to  labial  and  reverse.  They  are 
removed  by  direct  pull  after  the  tooth  is  felt  to  loosen. 

Of  Cuspids. — For  the  extraction  of  the  upper  cuspid 
the  same  forceps,  bayonet  shaped,  are  used  as  for  incisors 
and  bicuspids. 

The  root  of  the  upper  cuspid  is  longer  than  that  of 
any  other  tooth  in  the  mouth,  and  is  usually  very  firmly 
fixed  in  the  alveolus.  The  cross  section  of  the  root  at 
the  neck  is  very  similar  to  the  central.  It  is  roughly 
triangular,  with  much  rounded  angles.  Progressively  to- 
ward the  apex  it  becomes  more  or  less  round,  with  a  ten- 
dency to  an  oval  form,  the  longer  diameter  being  from 
labial  to  lingual.  To  loosen  this  tooth  the  rotary  move- 
ment is  applicable,  and  as  it  is  a  very  strong  tooth,  heavy 
pressure  may  usually  be  safely  applied.  It  will  often  be 
necessary  to  supplement  this  by  a  labio-lingual  rocking 
movement.  As  soon  as  the  tooth  is  felt  to  move  in  its 
socket  it  is  usually  easily  removed. 

For  the  lower  cuspid  the  forcep  known  as  the  lower 
bicuspid  is  to  be  used.  The  lower  cuspid  is  very  similar 
to  the  upper  cuspid,  except  that  it  is  more  slender  and 
the  root  has  a  greater  tendency  toward  the  oval  form. 
The  root,  also,  is  more  apt  to  be  crooked.  A  division  of 
the  tip  of  the  root  into  two  prongs  is  not  uncommon. 
On  account  of  these  differences  rotation  must  be  used  for 
loosening  with  more  caution  than  in  the  case  of  the  upper 
cuspid,  and  more  dependence  placed  on  the  lingual  and 
labial  to  and  fro  movement.  After  loosening  it  is  usu- 
ally not  difficult  to  remove. 

Of  Upper  Bicuspids. — The  upper  bicuspid  forcep  is  to 
be  selected  for  use  in  removing  the  upper  bicuspids. 
These  teeth  are  flat  rooted,  with  long  diameter  from  buc- 
cal to  lingual.  The  first  upper  bicuspid  is  often  two- 
rooted.     They  are  to  be  loosened  by  movements  from 


OPERATIVE  PROCEDURE  255 

buccal  to  lingual,  and  vice  versa.  The  grasp  of  the  for- 
cep  should  be  as  high  upon  the  root  as  possible.  Force 
should  be  applied  to  them  very  gradually  and  carefully. 
They  are  slender  and  very  easily  broken,  and  the  roots 
are.  often  removed  with  much  difficulty  if  broken  off  high 
up. 

Of  Lowek  Bicuspids. — Lower  bicuspid  forceps  should 
be  used  for  lower  bicuspids.  The  lower  bicuspids  are 
not  so  flat  as  the  corresponding  upper  teeth.  They  are 
much  more  slender  both  as  to  root  and  crown.  Rotation 
for  loosening  is  not  always  admissible,  and  extreme  care 
must  be  taken  in  applying  force  for  this  purpose,  as 
they  are  very  easily  broken. 

All  the  teeth  so  far  spoken  of  may  be  removed  with 
the  same  forceps,  that  is,  all  the  upper  with  the  upper 
bicuspid  forcep,  and  all  the  lower  with  the  lower  bicus- 
pid forcep. 

Extraction  of  Molar  Teeth.— On  account  of  the  great 
difference  in  size  and  shape  of  the  molar  teeth,  these  re- 
quire an  altogether  different  instrument.  The  general 
pattern  is  the  same  as  for  the  anterior  teeth,  both  upper 
and  lower,  but  the  instrument  is  much  heavier,  and  the 
beaks  are  so  formed  as  to  fit  the  molar  crowns,  thus 
causing  them  to  differ  in  both  form  and  size  from  those 
suitable  for  the  ten  anterior  teeth. 

Of  Upper  Molars. — The  upper  molar  having  two  roots 
on  the  buccal  side,  the  beak  fitted  for  that  side  is  pro- 
vided with  a  point  in  the  center,  intended  to  extend  be- 
tween the  bifurcation  of  the  roots,  while  the  lingual 
beak  is  simply  concaved.  This  difference  between  the 
buccal  and  lingual  beaks  necessitates  the  making  of  the 
forceps  for  the  upper  molars  in  pairs,  right  and  left. 

The  upper  first  molar  is  the  largest  tooth  in  the  mouth. 
It  has  three  roots,  two  buccal,  one  lingual.  The  buccal 
roots  are  slender  and  nearly  in  line  with  the  buccal  side 
of  the  tooth.  The  lingual  root  is  the  largest  and  di- 
verges much  more  from  the  axial  line  than  do  the  other 


256  EXTRACTION  OF  TEETH 

two.  To  loosen  this  tooth  the  forceps  arc  applied  to 
llic  neck,  forcing  the  beaks  as  high  as  possible.  Force 
is  then  applied,  tending  to  tip  the  tooth  to  the  buccal. 
This  application  of  force  should  never  be  sudden,  but 
very  gradual,  all  the  time  feeling  resistance,  applying 
more  and  more  force  until  the  tooth  loosens  or  the  limit 
of  safety  is  reached.  Usually  this  one  motion  will  suf- 
fice to  loosen  the  tooth.  If  it  does  not,  one  may  need  to 
reverse  the  direction.  In  any  case  one  is  always  careful 
never  to  apply  any  force  in  rotation.  Such  will  always 
result  in  fractured  roots. 

The  reasons  for  applying  the  force  toward  the  buccal 
are  two:  (a)  the  alveolar  process  on  the  buccal  side 
is  thin,  and  more  easily  broken  than  on  the  lingual; 
(b)  the  roots  on  the  buccal  are  nearly  on  a  line  with  the 
axis  of  the  tooth,  while  the  lingual  diverges  in  such  a 
manner  as  to  make  very  strong  resistance  to  force  di- 
rected toward  the  lingual  side.  As  soon  as  the  tooth 
is  felt  to  start,  the  opposite  force  should  be  applied,  and 
by  a  combination  of  the  two,  with  also  direct  pull,  the 
tooth  may  be  removed. 

The  situation  and  form  of  the  upper  second  molar  is 
so  nearly  like  the  upper  first  that  as  a  rule  the  same  di- 
rections apply.  The  roots  of  this  tooth  do  not  diverge  so 
much  from  the  axis  of  the  tooth.  They  are  more  apt  to 
be  joined  together  to  form  a  two-rooted  or  single-rooted 
tooth.  For  these  reasons  it  is  sometimes  best  to  use  a 
plain  beaked  forcep,  that  is,  one  without  the  point  in  the 
center  of  the  outer  beak.  The  application  of  force  and 
position  of  operator  and  forceps  is  the  same  as  for  the 
upper  first  molar. 

The  upper  third  molar  is  normally  of  the  same  shape 
as  the  other  molars.  Practically  it  is  almost  always 
much  smaller,  and  very  commonly  the  roots  are  fused 
together,  and  often  much  distorted.  The  forcep  for  this 
tooth  is  the  universal  upper  molar,  with  plain  beaks.  On 
account  of  the  posterior  position  of  this  tooth  a  special 


OPERATIVE  PROCEDURE  257 

instrument  called  the  upper  wisdom  or  upper  third 
molar  forcep  is  often  used.  This  differs  from  the  regu- 
lar upper  molar  universal  in  that  the  beaks  of  the  in- 
strument are  not  in  the  direct  line  with  the  handles,  as 
in  the  other  upper  forceps,  but  the  beak  joins  the  bayonet 
bend  at  a  slightly  acute,  instead  of  a  right  angle,  thus 
making  it  easier  to  grasp  the  tooth  situated  at  the  ex- 
treme posterior  portion  of  the  jaw. 

The  roots  of  this  tooth  are  very  apt  to  be  somewhat 
twisted  on  the  axis.  On  this  account  the  application  of 
force  for  loosening  is  a  somewhat  complicated  and  diffi- 
cult motion  to  describe,  being  a  combination  of  the  direct 
buccal  motion,  as  for  the  other  molars,  with  also  a  for- 
ward twist.  The  only  means  of  telling  how  much  twist- 
ing motion  to  apply  is  the  feeling  communicated  to  the 
hand  by  the  resistance  of  the  tooth.  Except  for  the 
difficulty  of  grasping  this  tooth,  on  account  of  its  posi- 
tion, it  is  usually  very  easily  removed. 

It  should  always  be  remembered  that  the  situation  at 
the  extreme  end  of  the  alveolar  process  of  the  upper  jaw 
makes  it  easy  to  seriously  fracture  the  process  at  this 
point.  Sometimes  when  the  roots  are  strong  and  firmly 
fixed,  a  large  fragment  may,  if  care  is  not  taken,  be 
broken  off. 

Of  Lower  Molars. — As  the  anatomical  form  of  the 
lower  molars  differs  from  that  of  the  corresponding 
upper  teeth,  so  the  beaks  of  the  forceps  used  differ  from 
the  beaks  of  the  upper  forceps.  The  handles  are  also 
differently  formed,  on  account  of  the  different  position 
of  the  operator,  which  has  been  described.  The  roots  of 
the  lower  molars  are  two  in  number,  one  mesial,  one 
distal.  The  bifurcation  is  very  near  the  crown.  Each 
beak  of  the  forceps  intended  for  lower  molars  has  a  point 
in  the  center,  so  shaped  and  curved  as  to  fit  it  to  enter 
the  bifurcation  of  the  roots. 

Removal  of  Lower  Molars. — In  extracting  teeth  from 
the  lower  jaw,  many  times  students  have  difficulty  in 


258  EXTRACTION  OF  TEETH 

seeing  the  tooth  upon  which  it  is  desired  to  place  the  for- 
ceps. To  prevent  the  instrument  from  hiding  the  tooth, 
the  handles  should  be  raised  sufficiently  that  the  tooth 
may  be  seen  from  under  the  beaks  instead  of  over  them. 

The  preliminary  grasping  of  the  tooth  is  the  same  as 
any  other,  using  the  hand  grasp  as  previously  described. 
The  forceps  should  be  carefully  placed  so  that  the  cen- 
tral points  of  either  beak  will  find  and  enter  the  bifur- 
cation of  the  roots.  The  buccal  and  lingual  grooves,  when 
not  obliterated,  will  serve  as  guides.  The  beaks  are 
forced  as  far  rootward  as  possible. 

The  first  step  in  the  loosening  process  is  taken  by  firmly 
closing  the  forceps  upon  the  tooth.  If  the  beaks  of  the 
instrument  used  are  properly  formed,  the  tooth  a  normal 
one,  and  care  has  been  taken  to  grasp  the  tooth  in  the 
proper  manner,  this  motion  alone  will,  in  many  cases,  by 
the  wedging  action  of  the  central  points  of  the  beaks, 
cause  the  tooth  to  rise  from  its  socket,  thus  loosening  it 
without  further  effort.  If  the  closing  of  the  beak  fails 
to  loosen  the  tooth,  a  rocking  motion  from  buccal  to  lin- 
gual and  vice  versa  should  be  given  the  tooth,  increasing 
the  force  applied  very  gradually  until  the  tooth  starts. 
Theoretically,  on  account  of  the  anatomy  of  the  lower 
alveolar  process,  this  force  should  be  applied  toward 
the  lingual,  just  opposite  to  that  required  for  loosen- 
ing the  upper  teeth.  In  many  cases,  however,  it  will  be 
found  on  trial  that  the  tooth  will  start  easier  toward  the 
buccal. 

In  any  and  every  case  as  much  force  should  be  used, 
slowly  and  carefully  applied  in  one  direction,  as  in  good 
judgment  the  tooth  will  bear  without  danger  of  fracture, 
then  change  should  be  made  to  the  opposite  direction,  and 
the  same  thing  done  until  the  tooth  starts.  Quick,  jerky 
motions  cause  more  pain,  are  more  dangerous  and  less 
effective  for  the  object  desired.  When  the  tooth  has 
become  loosened,  it  is  lifted  out  by  direct  force. 


OPERATIVE  PROCEDURE  259 

All  directions  for  lower  first  molars  apply  to  lower 
second. 

Lower  Third  Molar. — Directions  for  the  extraction  of 
the  lower  third  molar  may  naturally  be  divided  into  two 
parts:  (a)  cases  in  which  the  tooth  presents  in  normal 
position  and  condition,  in  which  case  its  extraction  dif- 
fers but  little  from  that  of  the  other  molars,  and  is  usu- 
ally not  difficult;  and,  (b)  cases  in  which  the  tooth  is 
abnormally  placed,  when  sometimes  the  operation  for 
its  removal  becomes  almost  a  major  surgical  procedure. 

Under  normal  conditions  the  root  of  the  lower  third 
molar,  while  typically  bearing  two  prongs,  is  more  often 
found  with  both  roots  fused  into  one.  The  root  has  an 
almost  constant  tendency  to  curve  with  the  apex  to  the 
distal,  sometimes  very  markedly  so.  "When  the  tooth 
is  in  normal  position,  the  procedure  as  for  first  and 
second  lower  molars  will  often  suffice. 

On  account  of  the  strong  curvature  of  the  root  to  the 
distal,  and  the  crowding  of  the  crown  between  the  crown 
of  the  second  molar  and  the  ascending  ramus  of  the  jaw, 
a  difficulty  is  often  met  with  which  is  not  easily  over- 
come by  the  use  of  ordinary  forceps.  In  such  cases  one 
may  have  recourse  to  the  instrument  known  as  the  lower 
wisdom  or  third  molar  elevator,  called  by  Winter  in  his 
"Exodontia,"  Lecluse's  Elevator. 

Lecluse's  Elevator. — This  elevator  is  a  triangular, 
wedge-shaped  instrument,  bent  on  the  flat  at  an  angle 
of  45°  more  or  less.  The  external  or  outer  portion  from 
angle  to  point  is  perfectly  flat,  while  the  internal  surface 
is  rounded  from  side  to  side.  All  edges  are  as  sharp  as 
possible.  In  use  the  instrument  is  forced  between  the 
second  and  third  molars,  as  near  the  edge  of  the  alve- 
olar process  as  is  feasible,  with  the  flat  side  toward  the 
distal.  The  action  of  the  wedge  shape  will  tend  to  dis- 
lodge the  third  molar  backward.  "When  the  blade  of  the 
elevator  is  forced  between  the  two  teeth  as  far  as  pos- 
sible, the  handle  is  swept  downward  in  the  arc  of  a  circle, 


260  EXTRACTION  OF  TEETH 

and  in  the  plane  of  the  blade.  It  should  be  noticed  par- 
ticularly that  the  handle  is  not  rotated  upon  its  own  axis. 
The  effect  of  this  motion,  if  correctly  done,  will  be  to  en- 
gage the  lower  sharp  edge  of  the  blade  with  the  anterior 
surface  of  the  third  molar.  The  rounded  surface  will 
roll  upon  the  edge  of  the  process,  being  prevented  from 
sliding  forward  by  the  second  molar.  The  combination 
of  these  motions  will  tend  to  raise  the  third  molar  from 
its  socket  and  tip  it  backward.  Here  one  must  be  sure 
no  leverage  is  brought  to  bear  upon  the  second  molar, 
as  is  often  mistakenly  done  while  using  this  elevator. 
If  successful  the  tooth  will  be  so  thoroughly  loosened 
that  it  may  be  picked  out  with  any  appropriate  instru- 
ment. 

Avoiding  Accidents. — One  must  bear  in  mind  that  this 
instrument  with  its  short  fulcrum  and  long  handle  is 
very  powerful,  and  if  not  used  with  judgment  and  care 
may  produce  serious  results.  The  most  common  acci- 
dent met  with  in  the  use  of  the  third  molar  elevator  is 
the  snapping  off  of  the  crown  at  the  level  of  the  alveolar 
process,  a  most  distressing  accident.  It  is  perfectly 
possible,  by  careless  use  of  this  instrument,  to  produce 
an  actual  fracture  of  the  body  of  the  mandible,  a  more 
distressing  accident  still. 

Removal  of  Roots 

Roots  of  upper  incisor  teeth  if  simply  broken  off  at 
the  gum  margin,  or  slightly  below  the  same,  are  usually 
most  easily  removed  by  the  use  of  a  narrower  beaked 
forcep  of  the  same  general  pattern  as  the  regular  incisor 
forcep.  The  motions  for  loosening  and  extracting  are 
the  same  as  for  solid  teeth. 

Instruments  for  Extraction.— In  extracting  roots  with 
forceps,  the  use  of  instruments  with  too  narrow  beaks  is 
to  be  avoided.  While  in  some  cases  the  beaks  of  these 
narrow  forceps  may  more  easily  be  forced  under  the 


OPERATIVE  PROCEDURE  261 

gum  and  between  the  process  and  the  root,  at  the  same 
time,  with  them,  it  is  much  more  difficult  to  secure  a  cen- 
tral hold  upon  the  root,  and  therefore  the  liability  of  the 
forcep  to  slip  upon  the  root  is  greatly  increased. 

Of  Incisors. — For  badly  broken  down  incisor  roots, 
the  straight  spoon  elevator  may  often  be  used.  This  is 
to  be  forced  between  root  and  process  as  high  as  pos- 
sible. The  sharp  end  or  edge  of  the  elevator  engages  the 
root,  and  strong  pressure  is  then  made  toward  the  labial 
surface  and  downward.  The  root  will  often  slip  out 
after  the  application  of  but  little  force.  If  successfully 
done  this  method  will  remove  a  very  badly  broken  down 
root  with  surprisingly  little  laceration  of  the  gum.  In 
some  cases  the  right  angle  elevator  will  be  preferable. 
Roots  of  incisors  which  are  almost  entirely  hollowed 
out  by  decay  may  sometimes  be  removed  by  the  use  of 
a  screw  elevator.  This  instrument  is  simply  a  slender, 
gimlet  pointed  screw,  mounted  upon  the  end  of  a  straight 
shaft.  The  point  is  screwed  into  the  hollow  of  the  root, 
and  by  a  combination  of  rotatory  and  dragging  motions 
the  root  may  sometimes  be  removed.  For  very  badly 
broken  down  and  splintered  incisor  roots,  a  short-bladed, 
stout,  obtuse-angled  hatchet  excavator  is  often  the  most 
serviceable  instrument.  It  is  to  be  used  in  any  manner 
indicated  by  the  conditions  found. 

The  roots  of  lower  incisors  are  often  more  difficult  to 
remove  than  those  of  the  upper.  Fortunately  they  are 
more  seldom  met  with.  The  lower  incisor  or  root  for- 
ceps are  usually  indicated,  or  sometimes  the  right  an- 
gled, double  end,  or  Coolidge  elevator. 

Or  Cuspid. — Cuspid  roots,  both  upper  and  lower,  are 
often  removed  with  extreme  difficulty.  All  methods  as 
indicated  for  incisors  may  be  tried.  Some  one  of  them 
will  usually  be  found  applicable.  The  roots  being  very 
long  and  firmly  set,  it  will  usually  be  found  that  forceps 
cf  some  sort  are  indicated.  If  it  is  impossible  to  secure 
a  firm  hold  upon  these  roots  by  forcing  the  blades  of 


262  EXTRACTION  OF  TEETH 

the  forceps  between  the  process  and  the  root,  it  is  allow- 
able to  grasp  the  outside  of  the  process  and  crush  through 
it,  removing1  bone  and  root  together.  The  incisor  forceps, 
with  what  are  known  as  alveolar  beaks,  are  best  for  cases 
such  as  these.  It  is  even  allowable,  in  certain  very  diffi- 
cult cases,  to  make  the  grasp  outside  gum,  process  and 
all.  If  this  is  done  the  forceps  should  be  removed  and 
a  new  grasp  taken,  as  soon  as  the  process  is  felt  to 
yield,  this  in  order  to  prevent  a  too  severe  laceration  of 
the  gum  tissue. 

Of  Bicuspids. — Roots  of  the  bicuspid  teeth  are  to  be 
treated  essentially  as  are  the  roots  already  spoken  of. 
If  they  are  solid,  that  is  not  badly  hollowed  out,  or  not 
decayed  to  too  great  a  distance  below  the  gum  line,  the 
ordinary  root  or  bicuspid  forceps  are  suitable  instru- 
ments for  use.  If  they  are  very  badly  decayed  these 
roots  sometimes  present  many  difficulties. 

Coolidge  Elevator. — The  Coolidge,  or  right-angled,  or 
butterfly  elevator  (all  names  for  the  same  instrument) 
is  the  instrument  which  most  commonly  furnishes  a  so- 
lution of  the  difficulty.  This  instrument,  one  of  the 
most  useful  in  the  extractor's  kit,  requires  for  its  suc- 
cessful use  both  study  and  practice.  Many  operators, 
some  of  them  good  ones,  never  acquire  the  knack  of  using 
it.  Many  other  elevators  of  the  same  general  type,  and 
intended  for  the  same  purpose,  are  in  the  market,  but 
this  form  seems  more  nearly  to  fulfil  all  requirements 
than  any  other. 

In  use  the  sharp  end  of  the  blade  is  to  be  inserted  be- 
tween the  edge  of  the  process  and  the  surface  of  the  root 
to  be  extracted.  There  is  sometimes  some  difficulty  in 
finding  this  point.  When  found,  however,  the  blade  is  to 
be  forced  into  the  space  as  far  as  possible.  Often  the 
mere  forcing  in  of  the  blade  will  loosen  the  root  suffi- 
ciently to  make  its  complete  removal  easy. 

If  the  root  does  not  start  at  once,  force  is  further  to 
be  applied  by  so  turning  the  handle  that  the  sharp  edge 


OPERATIVE  PROCEDURE  263 

of  one  side  of  the  blade  will  be  brought  into  contact  with 
the  side  of  the  root ;  then,  by  making  a  long  sweep  with 
the  handle,  upward  or  downward,  as  the  case  may  be,  the 
sharp  side  of  the  blade  engaging  the  body  of  the  root, 
while  the  rounded  surface  rolls  upon  the  edge  of  the 
process,  the  root  will  usually  be  lifted  from  the  socket 
and  its  removal  easily  accomplished.  The  effect  is  that 
of  a  lever  with  the  fulcrum  very  near  the  weight  to  be 
moved.  If  this  operation  is  carried  out  as  described, 
very  firmly  imbedded  roots  may  often  be  removed  with 
ease,  and  with  surprisingly  little  laceration  of  the  sur- 
rounding tissues. 

The  most  common  mistake  that  is  made  in  the  use  of 
the  elevator  is  that  of  using  the  point  of  the  instrument, 
instead  of  the  side,  as  the  lever.  This  lengthens  the  dis- 
tance from  the  weight  to  the  fulcrum  very  materially, 
and  results  in  two  defects:  (a)  lack  of  power;  and  (b) 
extreme  breaking  and  laceration  of  tissue  if  the  root 
yields.  Of  course  the  point  is  often  used,  but  most  of 
the  failures  come  from  lack  of  appreciation  of  the  fact 
that  the  side  of  the  blade  is  most  useful  in  difficult  cases. 

Sometimes  a  bicuspid  root  which  seems  to  be  difficult, 
especially  one  which  is  decayed  or  broken  off  far  below 
the  edge  of  the  process,  may,  with  apparent  ease,  be  se- 
cured by  forcing  a  stout,  very  short-bladed,  right-angled 
excavator  flatwise  between  the  process  and  the  root. 
When  it  is  deep  enough  so  that  the  edge  of  the  blade  will 
engage  the  body  of  the  root  the  shank  is  slightly  rotated, 
thus  causing  the  point  of  the  excavator  to  catch  in  the 
surface  of  the  root.  When  this  has  been  done  a  con- 
siderable force  may  be  exerted  in  a  vertical  direction, 
many  times  resulting  in  the  dislodgment  of  the  offending 
root. 

Removal  of  Upper  Molars. — Paradoxical  as  it  may 
seem,  the  roots  of  the  upper  molars  are  both  easy  and 
difficult  of  extraction. 

If  the  three  parts  of  the  root  of  the  upper  molar  are 


264  EXTBACTION  OF  TEETH 

widely  separated,  each  part  is  usually  easily  removed 
separately,  either  with  small  forceps,  or  if  deeply  im- 
bedded in  the  tissues,  the  Coolidge  elevator  skillfully 
wielded.  In  these  cases  the  elevator  is  to  be  used  as  in- 
dicated when  speaking  of  bicuspid  roots. 

If  the  three  portions  of  the  roots  are  still  joined  to- 
gether, or  if  separate  but  still  close  to  each  other,  it  may 
be  very  difficult  to  bring  force  to  bear  on  them  separately, 
with  either  instrument.  In  such  a  case  it  is  sometimes 
feasible  to  grasp  the  three  portions  as  a  whole  with  an 
alveolar  bicuspid  forcep,  carrying  the  beaks  as  high  upon 
the  mass  as  possible.  When  pressure  is  brought  to  bear 
by  closure  of  the  handles,  the  tendency  is  to  force  the 
three  part's  together,  breaking  the  septa  of  bone  between 
them,  and  thus  loosening  the  whole.  When  this  has  been 
done  it  will  in  many  cases  be  easy  to  pick  out  each  root 
separately  and  thus  finish  the  operation  with  little  lacer- 
ation of  tissue,  and  with  less  pain  to  the  patient  than 
in  any  other  way. 

When  the  roots  are  separate,  or  when  loosened  and 
separated  by  pressure  of  the  forceps,  it  is  usually  best 
and  easiest  to  remove  first  the  lingual  root.  As  that 
root  is  much  larger  and  stronger  than  the  two  buccal, 
its  removal  acts  somewhat  like  the  removal  of  the  key- 
stone of  an  arch.  The  supporting  member  having  been 
taken  away,  the  remaining  members  fall  out  easily. 

Of  Lower  Molars. — In  every  lower  molar  extraction 
the  tooth,  previous  to  the  commencement  of  the  opera- 
tion, should  be  carefully  examined  with  the  view  of  de- 
termining the  strength  of  the  crown.  If  the  crown  is 
evidently  seriously  weakened  by  decay,  it  is  well  to  pro- 
ceed in  every  case  upon  the  supposition  that  there  is 
a  root  extraction  to  deal  with. 

If  one  tries  to  use  the  lower  molar  forcep  upon  a  seri- 
ously weakened  tooth  the  result  usually  will  be  the  break- 
ing off  of  the  crown  low  down,  with  the  roots  left,  still 


OPERATIVE  PROCEDURE  265 

firm  in  their  sockets.  In  such  a  case  the  remaining 
portion  may  be  difficult  to  extract,  as  the  process  may 
be  firm,  and  the  roots  broken  so  low  down  that  no  guide 
is  left  to  direct  any  instrument  into  position  for  their 
removal. 

If,  on  the  other  hand,  one  selects  a  forcep,  preferably 
of  the  bicuspid  type,  guiding  the  instrument  on  to  the 
anterior  or  posterior  root,  as  the  condition  of  the  tooth 
may  seem  to  indicate,  and  forcing  the  beaks  as  far  down 
as  possible,  one  exerts  force  as  one  would  for  any  lower 
single-rooted  tooth.  In  fortunate  cases  the  whole  tooth 
may  be  loosened  and  easily  removed.  Under  less  fortu- 
nate, but  still  favorable  conditions,  the  root  grasped  is 
easily  removed,  leaving  the  remaining  one  to  be  taken 
out  separately,  either  with  forceps  or  with  elevator,  as 
may  seem  best. 

If  an  unfortunate  case  exists  and  the  grasp  upon  the 
first  root  attempted  fails,  there  still  remains  the  second 
root  upon  which  one  may  operate  in  the  same  manner. 

In  cases  where  the  crown  is  wholly  gone,  and  the  roots 
are  separate,  it  is  usually  best  to  start  the  operation 
with  the  elevator.  Usually  such  roots  are  among  the 
least  difficult  with  which  one  has  to  deal,  when  properly 
approached. 

Extraction  of  Impacted  and  Misplaced  Teeth 

Many  cases  are  met  with  in  which,  from  one  cause  or 
another,  teeth  erupt  out  of  proper  position.  Often  when 
removal  of  these  teeth  is  required,  one's  skill  and  in- 
genuity are  tasked  to  the  utmost.  Unerupted  teeth  also 
often  are  sources  of  trouble,  and  may  require  removal. 
The  variations  in  these  cases  are  so  many,  and  the  po- 
sitions assumed  by  the  teeth  are  so  varied,  that  the  opera- 
tion for  their  removal  can  only  be  touched  upon  in  a 
general  way. 


266  EXTRACTION  OF  TEETH 

Deformities 

Deformity  of  Bicuspid.— Of  the  deformities  commonly 
met  with,  one  quite  often  sees  an  irregular  eruption  of 
one  of  the  bicuspids,  either  upper  or  lower.  One  of  these 
teeth  is  often  forced  to  take  its  place  entirely  out  of  line, 
either  within  or  without  the  arch.  The  crown  may  pre- 
sent with  its  axis  in  the  same  vertical  line  with  those  of 
the  other  teeth,  or  it  may  point  in  almost  any  direction. 
On  account  of  the  crowding  the  roots  of  these  teeth  are 
often  very  crooked. 

The  problem  is  to  find  some  instrument  or  form  of 
forceps  with  which  the  tooth  may  be  firmly  grasped,  and 
then  to  carefully  loosen  and  finally  remove  it.  The  prob- 
lem is  made  more  difficult  by  the  fact  that  the  misplaced 
tooth  is  usually  crowded  closely  into  the  embrasure  be- 
tween two  other  teeth,  and  thus  the  operator  is  prevented 
by  the  crowding  from  using  the  regular  forceps.  Often  a 
strong,  narrow-beaked  instrument  similar  to  the  pattern 
of  forcep  known  as  the  Hawk-bill  may  be  used. 

When  one  has  succeeded  in  getting  an  instrument  to 
grasp  the  tooth,  one  may  proceed  very  carefully  to  loosen 
it.  In  doing  this  one  must  use  extreme  caution,  trying 
motions  in  every  direction,  and  at  first  with  little  force, 
for  the  breaking  off  of  the  crown  of  such  a  tooth  may,  and 
often  does,  entail  an  operation  of  considerable  magnitude 
for  the  removal  of  the  root. 

Unerupted  Teeth.— Unerupted  teeth,  if  removal  is  re- 
quired, sometimes  present  serious  difficulties.  Upper 
cuspids  and  lateral  incisors  are  the  teeth  most  commonly 
found  in  this  condition. 

Mistaken  for  Cancer. — The  presence  of  these  un- 
erupted teeth  is  often  not  suspected  until  some  time  after 
the  remaining  teeth  have  been  lost  and  artificial  substi- 
tutes inserted.  After  a  varying  lapse  of  time,  a  tumor 
may  appear  somewhere  under  the  plate,  which  breaking 
down  leaves  a&  open  ulcer  or  cavity.    The  plate  cannot  be 


OPERATIVE  PROCEDURE  267 

worn,  and  the  patient  often  becomes  greatly  alarmed 
about  the  condition,  especially  if  some  inexperienced  ad- 
visor (and  such  a  diagnosis  is  often  made)  proclaims  the 
trouble  to  be  a  cancer  or  some  other  serious  lesion.  The 
most  common  diagnosis  is  "bone  cancer."  Examination 
with  probe  reveals  a  hard  tissue  near  the  opening  in  the 
gum,  the  outlines  of  which  are  very  often  difficult  to  de- 
termine on  account  of  the  presence  of  caries  or  deposits 
of  calculus.  It  may  safely  be  said  that  any  such  condition 
is,  ninety-nine  times  in  one  hundred,  caused  by  an  un- 
erupted  tooth. 

Removal. — For  the  removal  of  these  teeth,  a  free  in- 
cision of  the  gum  is  required,  outlining  one  or  more  flaps ; 
these  are  separated  from  the  underlying  bone  by  the  use 
of  the  periosteal  elevator,  thus  gaining  a  clear  view, 
after  bleeding  has  ceased,  of  the  field  of  operation.  Hem- 
orrhage, which  probably  will  be  free,  may  be  controlled 
by  the  use  of  gauze  packings.  After  the  tooth  and  bone 
surrounding  it  are  exposed  and  clearly  in  view,  as  much 
of  the  bone  by  the  side  of  the  tooth,  or  from  both  sides, 
should  be  removed,  either  with  chisel  and  mallet,  or  with 
burrs  in  the  engine,  as  will  enable  the  operator  to  grasp 
the  tooth  firmly  with  a  pair  of  forceps.  When  this  has 
been  done,  the  removal  is  usually  easily  accomplished.  If 
hemorrhage  continues,  it  should  be  controlled  by  firm 
packing,  which  may  be  left  in  place  not  longer  than 
twenty-four  hours.  Otherwise,  and  if  packing  is  used, 
after  its  removal,  simple  rinsing  of  the  mouth  with  nor- 
mal salt  solution  will  be  all  that  is  required.  Healing 
will  usually  be  complete  and  uneventful. 

Deformity  of  Lower  Third  Molar.— The  lower  third 
molar  ordinarily  is  not  a  difficult  tooth  to  extract,  provid- 
ing the  anatomy  of  the  tooth  and  surrounding  parts  be 
remembered ;  but  from  its  tendency  to  vary  both  in  posi- 
tion and  form  results  the  exceptional  case  where  the 
operation,  instead  of  an  easy  and  simple  one,  becomes 
exceedingly  difficult.     One  may  be  in  practice  for  many 


268  EXTRACTION  OF  TEETH 

years  and  never  see  a  case  out  of  the  ordinary;  again  the 
first  ease  to  present  may  be  full  of  difficulty.  Unerupted 
third  molars  have  been  found  in  almost  every  imaginable 
position  in  the  jaw.  The  more  common  form  is  where  the 
tooth  attempts  to  erupt  in  proper  position,  but  with  the 
crown  presenting  forward.  In  such  cases  some  part  of 
the  crown  impinges  upon  the  second  molar,  which  in  con- 
junction with  the  ascending  ramus  acts  as  a  stop  to  the 
further  eruption  of  the  tooth,  and,  as  it  were,  traps  it  in 
its  abnormal  position. 

Symptoms  Accompanying  Deformity. — The  symptoms 
attending  impaction  or  malposition  are  many,  sometimes 
very  severe,  but  often  obscure.  When  entirely  unerupted 
there  may  be  severe  facial  neuralgia  with  no  apparent 
cause.  If  in  neuralgic  cases  no  third  molar  is  present, 
and  no  history  of  its  extraction  can  be  obtained,  the  re- 
gion should  be  explored  by  means  of  the  X-ray.  Some 
puzzling  cases  have  thereby  been  cleared  up.  The  cause 
of  the  pain  may  be  from  pressure  on  the  main  nerve 
trunk  in  its  course  through  the  body  of  the  jaw,  or  it  may 
be  from  erosion  of  the  root  of  the  second  molar,  caused 
by  the  impingement  of  the  crown  of  the  impacted  tooth. 
When  the  tooth  has  erupted  so  far  as  to  show  some  por- 
tion of  the  crown  above  the  surface  of  the  gum,  still 
being  impacted,  there  may  be,  beside  neuralgia  (which, 
bear  in  mind,  is  not  a  disease,  but  merely,  as  the  name 
implies,  a  nerve  pain),  many  other  troubles  mainly  due 
to  infective  processes,  either  of  the  pulp  of  the  impacted 
tooth  or  of  the  soft  tissues  or  bone  adjacent. 

From  its  protected  position  a  partially  erupted  third 
molar  is  very  liable  to  decay.  The  disintegration  of  the 
tooth  may  proceed  so  far  and  so  insidiously  as  to  cause 
the  death  of  the  pulp  with  little  or  no  warning  other  than 
fleeting  or  transient  pains.  The  final  result,  as  in  any 
other  tooth,  is  alveolar  abscess.  The  swelling  in  these 
cases  is  apt  to  be  very  great.  It  is  not  uncommon  to  see 
cases  in  which  the  patient  is  unable  to  separate  the  jaws 


OPERATIVE  PROCEDURE  269 

even  enough  to  admit  a  mirror.  The  swelling  from  its 
proximity  to  the  entrance  to  the  opening  of  the  trachea 
and  esophagus  may  become  dangerous.  There  may  be 
considerable  suppuration  and  even  necrosis  about  an  im- 
pacted third  molar  when  the  pulp  is  not  involved.  Such 
conditions  are  often  due  to  the  bruising  of  the  overlying 
tissue  in  the  act  of  mastication. 

The  removal  of  the  ordinary  third  molar  has  been  pre- 
viously spoken  of.  In  cases  suspected  of  being  impacted, 
whether  the  tooth  be  entirely  unerupted  or  partially 
visible,  skiagraphs  should  be  made  in  every  case  previous 
to  any  operation  for  removal.  The  resulting  pictures 
may  be  of  much,  little,  or  no  value.  At  least  one  will  have 
the  satisfaction  of  having  done  everything  possible  to 
determine  the  position  and  condition  of  the  tooth.  It  is 
taken  for  granted  that  every  possible  exploration  with 
probe  and  mirror  has  already  been  made.  There  are  so 
many  variations  in  position  and  conditions  met  with  that 
it  is  obviously  impossible  to  give  any  detailed  description 
of  the  operation. 

Operative  Procedure. — In  general  it  will  be  about  as 
follows :  As  a  first  step  an  incision  should  be  made  long 
enough  to  thoroughly  uncover  the  space  occupied  by  the 
tooth.  If  the  tooth  is  unerupted,  this  incision  should  be 
well  toward  the  lingual  side  of  the  process.  This  incision 
should  be  in  the  line  of  the  jaw,  then  either  by  continuing 
the  original  incision  in  a  curved  line,  or  by  making  a 
second  cut  across  the  jaw,  just  to  the  distal  of  the  second 
molar,  and  well  down  to  the  cheek,  a  flap  should  be  out- 
lined. This  should  be  dissected  from  the  bone  by  the  use 
of  periosteal  elevators.  Bleeding  will  probably  be  free, 
and  after  raising  the  flap,  and  before  proceeding  further, 
should  be  checked  by  firm  packing  with  gauze,  or  other 
appropriate  means.  After  bleeding  is  stopped  so  that 
the  field  may  easily  be  seen,  one  proceeds  with  chisel  and 
mallet,  or  with  burrs,  as  seems  most  convenient,  to  re- 
move the  bone  from  above,  and  often  from  one  side  of  the 


270  EXTRACTION  OP  TEETH 

tooth.  This  is  easily  said  but  in  many  cases  is  quite  diffi- 
cult to  do. 

After  a  sufficient  amount  has  been  removed,  or  what 
seems  to  be  sufficient,  one  may  try,  either  with  forceps  or 
elevator,  to  remove  the  tooth.  If  unsuccessful,  and  by 
that  is  meant  if  the  tooth  does  not  yield  upon  the  applica- 
tion of  a  moderate  force,  the  situation  must  be  studied 
to  determine  whether  to  remove  more  bono,  and,  if  so,  in 
what  direction;  or  whether  to  attempt  the  cutting  of  the 
tooth  in  two.  This  latter  sounds  like  an  easy  solution 
but,  like  many  other  easily  described  operations,  may 
present  many  difficulties. 

In  the  end,  somehow,  the  tooth  is  removed.  The  extent 
of  cavity  left  in  the  bone  will  often  be  surprising.  As 
after-treatment  it  is  often  well,  especially  if  there  be 
much  tendency  to  hemorrhage,  to  insert  a  firm  packing  of 
sterile  gauze.  This  packing  should  under  no  conditions 
be  left  in  place  longer  than  twenty-four  hours. 

Further  treatment  should  consist  only  of  copious  and 
frequent  irrigations  of  the  wound  with  a  bland  wash, 
such  as  normal  salt  solution.  This  may  be  done  by  the 
patient.  Forcible  syringing  or  probing  of  the  wound, 
unless  it  becomes  septic,  should  be  avoided.  Many 
wounds  which  might  otherwise  do  well,  become  septic 
from  overtreatment.  The  desire  to  do  something  often- 
times produces  the  very  result  one  is  aiming  to  avoid. 
This  applies  to  many  other  surgical  conditions. 

Common  Accidents  in  Extraction 

All  operations,  even  the  most  careful,  sometimes  have 
accidents.  Some  are  unavoidable.  Others,  like  the  ex- 
tracting of  the  wrong  tooth,  are  due  to  carelessness,  and 
should  never  happen. 


OPERATIVE  PROCEDURE  271 

Fractures 

Of  the  Teeth.— The  most  common  accident  is  fracture 
of  the  tooth  itself.  This  often  happens  to  everyone,  but 
may  largely  be  avoided  by  careful  examination  previous 
to  undertaking  operation,  and  care  in  selecting  suitable 
instruments.  In  extracting  badly  broken-down  teeth,  the 
patient  should  be  warned  of  the  danger  of  fracture  of  the 
tooth.  Whenever  this  accident  does  happen,  one  need  not 
be  discouraged,  but  one  can  get  a  different  instrument 
and  dig  deeper.  One's  mind  should  be  made  up  to  get 
every  tooth  one  tries  for. 

Of  the  Alveolar  Process.— Another  not  uncommon  ac- 
cident is  fracture  of  the  alveolar  process.  This  is  not, 
strictly  speaking,  an  accident,  as  more  or  less  fracture 
must  occur  in  every  extraction.  It  is  only  when  large 
pieces  are  split  off  that  it  is  regarded  as  anything  out 
of  the  ordinary.  When  small  pieces  of  the  process  adhere 
to  the  tooth  and  are  removed  with  it,  no  harm  is  done ; 
but  it  is  well  to  remove  them  from  the  tooth  before 
showing  it  to  the  patient,  lest  one  be  charged  with  break- 
ing the  jaw.  Sometimes,  especially  in  the  upper  jaw, 
large  pieces  of  the  outer  plate  of  the  alveolus  may  split 
off.  If  one's  movements  are  slow,  as  they  should  be,  such 
an  accident  will  be  observed  before  the  piece  is  removed, 
and  means  should  be  taken  to  separate  it  from  the  tooth 
before  finishing  the  operation.  Afterward,  if  the  piece 
is  very  large,  it  should  be  pushed  back  into  place,  and 
allowed  to  reunite  with  the  bone  to  which  it  was  origi- 
nally attached.  If  large,  jagged  pieces  of  process  are 
pulled  out  with  the  tooth  there  is  apt  to  be  a  consider- 
able laceration  of  the  gum,  and  possibly  considerable 
hemorrhage. 

If  the  tuberosity  of  the  superior  maxilla  is  the  point 
broken  off,  ono  must  be  very  sure  to  separate  it  from 
the  tooth  and  leave  it  in  place.  Severe  hemorrhage  is 
apt  to  follow  laceration  in  this  part  of  the  oral  cavity, 


272  EXTRACTION  OF  TEETH 

which  may  be  hard  to  control.    Injury  to  various  nerves 
may  also  be  caused. 

Actual  fracture  of  the  body  of  the  bone  is  mentioned 
by  various  authors  as  an  accident  which  may  happen. 
But  the  chance  of  such  an  accident  is  very  remote,  un- 
less previous  disease  exists. 

Hemorrhage 

Hemorrhage  of  more  than  ordinary  amount  will  prob- 
ably be  met  with  by  every  extractor  at  some  time  or 
other. 

The  best  means  for  controlling  hemorrhage  is  pres- 
sure, exerted  by  means  of  gauze  sponges.  The  pressure 
may  be  applied  in  various  ways.  In  most  cases  simple 
packing,  once  or  twice  repeated,  will  usually  suffice.  A 
dusting  of  tannic  acid  or  powdered  alum  on  the  surface 
of  the  packing  may  help.  In  more  severe  cases,  a  tight 
packing  may  sometimes  be  held  in  place  by  a  figure-of- 
eight  ligature  between  two  adjacent  teeth,  passing  over 
the  top  of  the  packing.  Again,  the  packing  may  be  made 
large  enough  to  extend  above  the  crowns  of  the  adja- 
cent teeth,  and  held  in  place  by  closing  the  jaw  upon  it. 
If  all  other  means  fail,  a  surgeon's  services  should  be 
procured  and  such  means  taken  as  injection  of  rabbit 
serum. 

Dropping  of  Tooth 

Allowing  a  tooth  to  slip  from  the  forceps  and  pass 
down  the  trachea  is  a  most  distressing  accident,  and  one 
very  apt  to  be  fatal  to  the  patient,  unless  immediately 
gotten  out,  either  by  tracheotomy  or  other  means. 

If  the  tooth  should  slip  into  the  esophagus,  no  harm 
will  be  done. 


OPERATIVE  PROCEDURE  273 

After  Treatment 

In  ordinary  cases  no  treatment  whatsoever  is  required, 
other  than  to  warn  the  patient  to  keep  the  mouth  clean 
with  rinsings  of  saline  solution.  If  apical  abscess  is 
present,  it  may  be  well  to  do  a  slight  curettement  of  the 
part.  The  writer  believes  that  most  cases  will  do  better 
without  interference,  unless  more  or  less  necrosis  is 
present.  In  such  cases,  of  course,  the  parts  should  be 
scraped  until  sound  bone  is  reached.  When  many  teeth 
are  extracted,  it  is  often  well  to  cut  out  the  septa  of  bone 
between  them,  and  press  the  sides  of  the  process  to- 
gether. Such  treatment  will  hasten  the  healing  and  ab- 
sorbing process,  and  tend  to  leave  a  more  symmetrical 
foundation  upon  which  to  place  artificial  substitutes. 

Dry  Socket.  — There  is  just  one  other  condition  that 
quite  often  arises  which  calls  for  a  word.  That  is  what 
used  to  be  known  as  dry  socket.  In  ordinary  cases  the 
socket  from  which  the  tooth  has  been  removed  fills  with 
a  clot  of  blood,  which  later  becomes  organized  during  the 
process  of  healing  and  repair.  Sometimes  the  patient 
returns  seeking  relief  from  pain  which  has  persisted 
over  one,  two,  or  more  days.  Upon  examination  one  finds 
the  socket  empty,  or  possibly  filled  with  debris,  and  very 
tender  and  painful.  There  are  many  remedies,  but  the 
most  successful  has  been  a  thorough  cautery  of  all  parts 
of  the  socket,  and  especially  the  extreme  apex,  with  95 
per  cent  carbolic  acid.  This  is  used  on  a  cotton  pellet, 
but  not  so  wet  that  the  acid  will  run  over  the  gum,  cheek 
or  lips  when  introducing  it.  One  application  will  almost 
always  be  sufficient. 


CHAPTER  IX 

NOVOCAIN  TECHNIC 

William  A.  Gobie,  D.  M.  D. 

MANDIBULAR  INJECTION 

Procedure. — The  retromolar  fossa  is  located  by  digital 
pressure  and  by  the  internal  and  external  oblique  lines. 
The  point  of  injection  is  situated  about  1  cm.  over  the  oc- 


Fig.  102. — A  Modern  Equipped  Table  fob  Novocain  Anesthesia. 

clusal  surface  of  the  last  molar.    It  is  necessary  to  ster- 
ilize the  point  of  injection  by  tincture  of  iodin. 

The  Needle. — The  needle  is  held  just  like  a  pen-holder 
and  inserted,  having  the  barrel  of  the  syringe  over  the 

274 


MANDIBULAR  INJPXTION 


275 


opposite  cuspid  and  first  bicuspid.  The  bevel  of  the 
needle  must  be  toward  the  bone  (Fig.  103).  The  needle 
should  follow  the  novocain  solution  and  is  then  inserted 
backward  and  outward  till  it  strikes  the  bone.  Here  it  is 
withdrawn  slightly  and  about  0.5  cc.  of  the  solution  is  in- 
jected for  the  lingual  nerve.    The  syringe  is  now  moved 


Fig.  103. — Showing  Direction  of  Needle  in  Mandibular  Injection. 


toward  the  side  to  be  anesthetized,  carefully  keeping  the 
needle  in  close  contact  with  the  inner  surface  of  the 
ramus,  and  inserting  it  one  inch,  injecting  in  the  sul- 
cus mandibulars  about  1.5  cc.  of  the  solution,  to  anesthe- 
tize the  inferior  dental  nerve  just  as  it  enters  the  canal. 
Then  the  needle  is  slowly  withdrawn,  injecting  all  the 
time.  The  whole  operation  must  consume  at  least  40  to 
60  seconds. 


Fig.  104. — Showing  Direction  of  Needle  and  Position  of  Syringe  and 
Hands  in  Mandibular  Injection. 


Fig.  105 Showing  Direction  of  Needle  in  Zygomatic  Injection. 

276 


ZYGOMATIC  INJECTION 


277 


Twenty  minutes  are  allowed  for  the  injection  to  take 
full  effect  and  produce  the  necessary  surgical  anesthesia. 
(See  cuts.) 


Fig.  106. — Position  of  Hands  and  Syringe  in  Zygomatic  Injection. 


ZYGOMATIC  INJECTION 

The  point  of  injection  is  located  at  the  distal  root  of 
the  upper  first  molar  at  a  point  where  the  buccinator 
muscle  meets  the  alveolar  process. 

The  point  of  injection  is  prepared  as  usual.  The  needle 
is  inserted  and  directed  backward,  inward  and  upward, 
keeping  in  close  touch  with  the  zygomatic  surface;  in- 
jecting all  the  time  as  one  goes  forward.  About  2  cc.  of 
the  solution  is  injected  and  the  needle  withdrawn  slowly. 


278 


NOVOCAIN  TECHNTC 


Fifteen  minutes  are  allowed  for  the  injection  to  take 
effect  and  produce  the  necessary  anesthesia.     (See  cuts.) 


INFRA-ORBITAL    INJECTION 

The  infra-orbital  foramen  is  located  by  digital  pres- 
sure.  Retraction  of  the  lips  is  made  and  after  preparing 
the  place  the  long  needle  is  inserted  in  the  canine  fossa, 


Fig.  10/. — Showing  Direction  of  Needle  in  Infra-orbital  Injection. 

as  high  as  the  reflection  of  the  mucous  membrane  al- 
lows, or  preferably  just  a  trifle  higher.  The  needle  is 
advanced  under  the  periosteum,  until  the  needle  point  is 
felt  under  the  palpating  finger.  About  1  cc.  of  the  solu- 
tion is  -lowly  injected,  at  the  same  time  massaging  the 


MENTAL  INJECTION  279 

cheeks  evenly,  so  as  to  drive  the  solution  into  the  fora- 
men. 

Ten  minutes  are  allowed  for  the  anesthesia  to  occur. 
{See  cut.) 


Fig.   108. — Showing  Direction   of   Needle   and  Position   of  Hands   in 
Infra-orbital  Injection. 


MENTAL  INJECTION 

The  lips  are  retracted  and  the  mental  foramen  is  lo- 
cated between  the  two  lower  bicuspids,  between  the  gingi- 
val and  inferior  alveolar  border.  After  preparing  the 
place  of  injection  as  usual,  the  needle  is  inserted  as  shown 
in  the  figure,  downward  and  slightly  backward.  About 
1  cc.  of  the  solution  is  injected  while  applying  pressure 
with  the  finger-tip.  For  the  lingual  aspect  about  0.5 
cc.  is  given.  This  will  give  anesthesia  for  the  bicuspids 
and  cuspid. 

Ten  minutes  are  allowed  for  the  solution  to  take  effect. 
{See  cut.) 


Fig.  109. — Showing  Direction  of  Needle  in  Mental  Foramen  Injection. 


Fig.  110. — Showing  Direction  of  Needle  in  Anterior  Palatine 
Injection. 

280 


POSTERIOR  PALATINE  INJECTION        281 

ANTERIOR  PALATINE  INJECTION 

The  anterior  palatine  canal  is  located  in  the  median 
line,  just  posterior  to  the  incisive  papilla.  The  point  of 
injection  is  prepared  as  usual  and  the  needle  inserted  up- 
ward and  backward  and  about  6  or  7  minims  of  the  solu- 
tion is  deposited. 

Five  or  ten  minutes  are  allowed  for  the  anesthesia  to 
take  effect. 


Fig.  111. — Showing  Direction  of  Needle  in  Posterior  Palatine 
Injection. 


POSTERIOR  PALATINE  INJECTION 


The  posterior  palatine  foramen  is  located  at  the  re- 
gion of  the  junction  of  the  soft  and  hard  palates  and  dis- 
tally  to  the  last  erupted  upper  molar.  Preparing  the 
point  of  injection  as  usual,  the  needle  is  inserted  toward 
the  foramen  in  a  straight  line.    About  5  or  6  minims  of 


Fig.  112. — Author's  Instruments  Brought  Down  to  a  Minimum  Num- 
ber. 1.  Lower  molar  forceps.  2.  Lower  anterior  teeth.  3.  Upper  molar 
forceps.  4  and  5.  Upper  root  and  molar  forceps.  6.  Special  elevator. 
7.  Fish-tail  elevator.  8  and  9.  Cryer  right  and  left  elevators.  [Numbers 
read  left  to  right.  J 


Fig.  113. — Proper  Position  op  Operator,  Hands  and  Forceps  in  Using 
Lower  Molar  English  Forceps.  (Note  particularly  the  position  of 
the  left  hand  in  supporting  the  jaw.) 

28? 


GASSERIAN  GANGLION  INJECTION        283 

the  solution  is  enough.    More  will  be  distressing  to  the 
patient,  as  it  will  also  anesthesize  the  soft  palate. 
Ten  minutes  are  allowed  for  the  anesthesia  to  occur. 


GASSERIAN   GANGLION   INJECTION 

This  injection  is  necessary  in  cases  of  surgical  opera- 
tions of  the  face,  tumor  operations,  or  in  resection  of  the 
maxillae. 


Fig.  114. — Proper  Technic  in  Lower  Eoot  Extraction  with  Special 
Elevator.  (Note  the  throat-packing  to  prevent  root  going  into  the 
pharynx;  and  also  the  proper  position  of  the  left  hand.) 

Hartel's  Technic. — According  to  the  famous  German 
authority,  Dr.  Hartel,  the  technic  of  injection  is  as  fol- 
lows:— The  place  of  injection  is  prepared  in  the  usual 
manner  and  the  needle,  which  should  be  5  or  6  ccm.  long, 
is  inserted  in  the  buccinator  muscle  opposite  the  gingi- 
val margin  of  the  second  upper  molar.  Anesthetization 
is  done  superficially  first  and  then  the  needle  is  pushed 


284 


NOVOCAIN  TECIINIC 


upward,  accompanied  by  finger  feeling  between  the  an- 
terior margin  of  the  ramus  of  the  Lower  jaw  and  the 
maxillary  tuberosity  to  the  fossa  infratemporalis.  After 
reaching  the  base  of  the  skull  the  direction  of  the  needle 
is  determined  by  looking  from  the  front  so  that  the  needle 


Fig.  115. — Proper  Position  of  Hands  and  Forceps  in  Extracting  Upper 

Right  Molar. 


points  exactly  toward  the  pupil  of  the  eye  on  the  same 
side ;  and  looking  from  the  side  the  needle  points  toward 
the  tuberculum  articulare  of  the  zygomatic  arch.  It  is 
necessary  to  feel  one's  way  forward  along  the  bone  to 
reach  the  third  division  of  the  fifth  nerve  where  it 
emerges  from  the  foramen  ovale.  Here  the  patient  ex- 
periences pain.     One  cc.  of  a  two  per  cent  (not  more) 


GASSERIAN  GANGLION  INJECTION        285 

novocain  is   slowly  injected  into  the   substance   of  the 
ganglion.     The  distance  up  to  the  point  is  five  to  six 


Fig.  116. — Showing  Proper  Method  of  Using  Special  Elevator  and  the 
Position  of  the  Left  Hand  to  Prevent  Luxation  of  the  Adjoining 
Tooth. 


centimeters.     Care  in  asepsis  is  necessary, 
is  tested  irnniediately. 


Anesthesia 


CHAPTEE  X 

SURGICAL  TECHNIC  AND  BANDAGING 
James  J.  Hepburn,  A.  B.,  M.  D. 

INFECTION  AND  ASEPSIS 

Antisepsis. — The  great  progress  which  surgery  has 
made  during  the  past  generation  has  been  due  to  the 
elaboration  of  an  aseptic  technic  more  than  to  any 
other  factor.  Its  growth  had  its  real  beginning  at  the 
hands  of  Lord  Lister  in  1867.  He  thought  that  wound 
infection  was  caused  by  microorganisms  in  the  air,  and, 
to  combat  them,  devised  an  apparatus  to  spray  the  field 
of  operation  and  surroundings  with  carbolic  acid  solution. 
This  was  followed  by  other  methods  of  disinfecting 
wounds,  such  as  the  use  of  oxygen,  nitrogen,  alcohol,  and 
so  on.    This  was  the  age  of  antiseptics. 

Asepsis.— Asepsis,  as  now  understood,  means  the 
absence  of  organisms;  absolute  sterility,  accomplished  by 
mechanical  cleansing,  chemicals,  heat,  or  all  three  com- 
bined. This  means  that  the  field  of  operation  and  every- 
thing which  comes  in  contact  with  it  must  be  free  from 
organisms. 

Causes  of  Infection.— Infection  in  a  wound  may  be  due 
to  imperfect  sterilization  of  dressings,  ligatures,  or  other 
materials  used  in  the  operation;  to  the  presence  of  or- 
ganisms in  the  skin  of  the  patient ;  or  it  may  be  caused 
by  the  introduction  of  organisms  into  the  wound  by  the 
surgeon  or  his  assistants.  The  last  is  probably  the  most 
frequent.  Careful  cleansing  and  scrubbing  of  the  patient 
and  all  persons  engaged  in  the  operation,  absolute  steril- 

286 


INFECTION  AND  ASEPSIS 


287 


ity  of  dressings  and  ligatures,  and  a  rigid  aseptic  technic, 
carefully  and  not  casually  maintained,  should  and  does 
obviate  wound  infection. 


Sterilization- 

Methods. — Heat  is  the  most  effective  sterilizing  agent, 
and,  preferably,  moist  heat.  Most  instruments  may  be 
sterilized  by  boiling.     Materials  which  will  not  stand 


Fig.  117. — Steam  Autoclave.     (From  Brewer's  "Text-book  of  Surgery.") 

boiling  may  be  sterilized  by  steam  under  pressure.  This 
is  accomplished  in  a  so-called  autoclave,  examples  of 
which  may  be  seen  in  every  hospital.  Various  chemi- 
cal agents  are  used  to  sterilize  the  skin,  but,  in  order 
to  be  effective,  they  must  be  preceded  by  a  thorough 
cleansing  with  soap  and  water. 


288      SURGICAL  TECIINIC  AND  BANDAGING 

Technic  — Without  entering  into  a  discussion  of  the 
relative  merits  of  various  methods,  let  it  suffice  to  indi- 
cate the  following  simple  and  effective  technic,  which 
is  in  daily  use,  and  which  has  given  excellent  results : 
first,  the  field  of  operation  is  scrubbed  and  a  generous 
margin  about  it,  with  soap  and  water,  for  six  or  eight 
minutes ;  second,  the  soap  is  rinsed  off  with  sterile  water ; 
third,  rinsing  is  done  again  with  70  per  cent  alcohol ; 
fourth,  the  field  is  swabbed  off  with  benzin;  fifth,  the 
field  is  painted  with  one-half  strength  tincture  of  iodin ; 
sixth,  the  patient  is  draped  w7ith  sterile  towels  and  sheets, 
leaving  only  the  operative  field  exposed. 

Equal  care  must  be  taken  in  the  preparation  of  the 
surgeon  and  his  assistants.  The  hands  and  arms  as  far 
as  the  elbow  should  be  scrubbed  with  a  stiff  brush  and 
plenty  of  soap  for  from  six  to  ten  minutes,  rinsed  in 
sterile  water,  and  then  immersed  in  70  per  cent  alcohol 
for  three  minutes.  When  this  is  completed  the  men 
should  all  put  on  gowns,  caps,  masks,  and  rubber  gloves, 
which  have  been  previously  sterilized. 

Materials 

Sutures.— Suture  materials  are  those  which  are  used 
to  repair  wounds.  A  ligature  is  a  piece  of  such  mate- 
rial used  to  tie  off  a  blood  vessel  in  order  to  prevent 
hemorrhage.  Catgut  is  the  most  commonly  used  for 
these  purposes.  It  is  obtainable  all  ready  sterilized,  in 
glass  tubes  or  in  paper  containers,  in  any  size  desired. 
Plain  catgut  disintegrates  in  the  tissues  in  five  or  six 
days  and  is  therefore  unsuitable  when  security  for  a 
longer  time  is  needed.  For  such  cases  catgut  impreg- 
nated with  chromic  acid  or  iodin  is  available.  These  are 
all  ultimately  absorbed.  Kangaroo  tendon  is  another  ab- 
sorbable suture  which  was  formerly  very  extensively 
used,  and  is  still  used  to  some  extent  when  great  and 
long-enduring  support  is  desired;  such  as  in  the  repair 


INFECTION  AND  ASEPSIS  289 

of  hernia,  or  the  suture  of  broken  bones.  Silk  thread 
and  linen  thread  impregnated  with  celloidin  are  both  un- 
absorbable.  They  are  used  most  extensively  in  intestinal 
surgery.  The  best  material  for  a  skin  suture  is  silk- 
worm gut.  This  is  sterilized  by  boiling,  has  great 
strength,  does  not  soften  in  the  tissues,  and  does  not  tend 
to  become  loose.  When  a  small  scar  is  desirable,  as  in 
operations  about  the  face,  horsehair  is  the  most  useful. 
This  material  has  neither  the  strength  nor  the  flexibility 
of  silkworm  gut,  but  when  carefully  applied,  is  effective 
and  leaves  a  better  looking  scar. 

Dressings. — Dressings  are  materials  used  to  remove 
blood  from  a  wound  during  an  operation,  or  to  absorb 
fluids  and  protect  a  wound  during  its  repair.  Of  the  va- 
rious substances  used  for  this  purpose,  one  need  men- 
tion only  the  one  which  has  supplanted  all  the  others,  and 
is  now  in  practically  universal  use;  namely,  absorbent 
gauze.  This  is  cheap,  always  obtainable,  easily  sterilized 
by  heat,  and  can  be  prepared  in  any  size  or  shape  desired. 

Deainage 

Drainage  is  one  of  the  most  important  of  all  surgi- 
cal principles;  so  much  so  that,  frequently,  the  manage- 
ment of  drainage  is  as  important  in  determining  the  out- 
come of  a  given  case  as  is  the  performance  of  the  opera- 
tion itself.  Drainage  means  that  some  steps  are  taken 
to  provide  an  outlet  through  which  secretions  may  es- 
cape from  the  depths  of  a  wound  to  the  surface.  It  is 
indicated  in  every  case  which  is  infected  from  the  start, 
or  which,  on  account  of  the  nature  of  the  injury,  presum- 
ably, will  become  septic,  or  in  cases  where  there  is  con- 
siderable bleeding. 

Types  of  Drains.— Formerly  rigid  tubes  of  glass  or 
metal  were  used  for  this  purpose,  but  on  account  of  their 
weight  and  rigidity  they  frequently  caused  damage  to 
the  surrounding  structures,  and  have  been  largely  dis- 


290      SURGICAL  TECHNIC  AND  BANDAGING 

carded.  Rubber  tissue,  soft  rubber  tubes,  and  gauze  are 
now  used  almost  entirely.  Gauze  drains  have  certain 
disadvantages;  they  quickly  adhere  to  the  surrounding 
tissues  and  therefore  cause  pain  on  their  removal;  they 
become  saturated  with  coagulated  secretions  in  a  short 


Fig.  118. — Drains  for  Clean  and  Suppurating  Wounds.  A,  Flat  gutta- 
percha drain  folded  on  a  probe  ready  for  insertion ;  B,  a  piece  of  gutta- 
percha tissue  of  the  same  size  as  A;  C,  horsehair  drain;  D,  soft  rubber 
tubes  of  various  sizes;  E,  cigarette  drain  of  gauze  in  a  rubber  finger 
cot;  F,  cigarette  drain  of  gauze  and  gutta-percha  tissue.  At  the  right, 
a  piece  of  gutta-percha  tissue  and  a  piece  of  gauze  each  the  size  of  those 
from  which  the  drain,  F,  was  made.     (Foote's  "Minor  Surgery.") 


time  and  act  more  as  plugs  than  as  drains,  therefore, 
when  used,  they  should  be  renewed  frequently. 

Clean  Wounds.— A  clean  wound,  in  which  the  hemor- 
rhage has  been  controlled,  should,  of  course,  be  sutured 
without  drainage.  An  obviously  septic  wound  should 
equally  certainly  be  drained.  Between  these  two  ex- 
tremes is  a  large  group  of  cases  for  which  the  indications 
may  not  be  so  clear.     The  best  procedure  in  such  cases 


SUTURING  WOUNDS  291 

is  to  "play  it  safe."  Otherwise  stated  the  principle  is, 
when  in  doubt,  drain.  Frequently  in  this  class  the  drain- 
age may  only  be  temporary;  in  which  case  one  has  had 
the  security  of  prophylaxis  against  infection  and  has 
lost  very  little  either  in  time  or  in  sightliness  of  the 
scar.  On  the  other  hand,  if  the  wound  does  become  sep- 
tic, adequate  treatment  has  already  been  provided. 

Septic  Wounds.— Septic  wounds  should  be  drained  as 
long  as  they  remain  so,  and  at  each  dressing  care  should 
be  taken  to  see  that  the  drain  reaches  to  the  bottom  of 
the  sinus.  Healing  then  takes  place  from  the  bottom 
upwards  and  there  is  no  chance  for  a  pocket  to  be  formed 
in  the  depths  of  the  wound. 

Hemorrhage 

Hemorrhage  is  always  bothersome  and  frequently  se- 
rious both  in  operative  and  traumatic  wounds.  The  field 
of  operation  becomes  obscured,  and  an  excellent  culture 
medium  is  provided  unless  the  blood  is  cleared  away  and 
the  bleeding  stopped.  Wounded  vessels  must  be  picked 
up  in  hemostatic  forceps  and  ligated  if  necessary.  Gen- 
eral oozing  in  the  wound  can  be  treated  by  pressure  ap- 
plied with  a  gauze  sponge.  When  the  bleeding  is 
considerable  and  its  source  cannot  be  found  and  effec- 
tively ligated,  it  is  best  to  pack  the  wound  tightly  and 
apply  a  firm  bandage. 


SUTURING   WOUNDS 

Approximation  of  Parts. —In  suturing  wounds  it  is  im- 
portant to  get  accurate  approximation  of  parts,  and  to 
replace  structures  as  near  as  possible  to  their  anatomical 
relations.  One  must  be  sure  that  the  structures  which 
one  sews  together  really  belong  together.  For  example : 
it  would  be  disastrous  to  suture  the  cut-off  end  of  the 


292      SURGICAL  TECHNIC  AND  BANDAGING 

median  nerve  to  the  cut-off  palmaris  longus  tendon,  un- 
der the  impression  that  one  was  repairing  the  median 
nerve.  Within  a  year  the  writer  saw  a  ease  in  which 
that  very  thing  had  been  done.  For  another  example  at- 
tention might  be  called  to  the  many  unsightly  scars 
which  are  often  seen  disfiguring  the  necks  of  friends 
and  patients.  Many  of  these  are  due,  without  question, 
to  the  failure  on  the  part  of  the  operating  surgeon  to 
approximate  accurately  the  platysma  myoides  muscle. 

For  suturing  the  deeper  layers  of  the  wound,  or,  in 
other  words,  for  buried  sutures,  some  kind  of  catgut, 
either  plain,  or  impregnated  with  some  chemical,  should 

be  used.  There  are  some  excep- 
tions to  this,  but  as  a  rule  an  ab- 
sorbable suture  is  needed,  and 
catgut  is  the  best  of  these.  For 
Fig.   119.— Continued   or     the  skin,  an  unabsorbable  suture 

Glover's  Suture      (Ber-      is  preferable  because  it  is  smaller 
nard  and  Huettc.)  *■ 

and  therefore  makes  smaller 
holes  in  the  skin,  and  because  it  is  not  affected  by  the 
body  fluids  and  therefore  is  effective  for  as  long  as  it  is 
needed.  Silkworm  gut  is  the  material  usually  used,  ex- 
cept for  the  face,  where  horsehair  is  preferable. 

Types  of  Stitch.— The  skin  may  be  closed  with  one  of 
four  types  of  stitch,  namely :  the  continuous  or  over-and- 
over;  the  interrupted;  the  intracuticular;  and  the  sub- 
cuticular. 

Continuous  Suture. — The  continuous  suture  is  the 
quickest  but  not  necessarily  the  best.  Accurate  approxi- 
mation is  more  difficult  and  a  distorted  scar  usually  re- 
sults. Further  it  presents  decided  disadvantages  in  the 
cases  where  the  wound  becomes  infected.  If  an  inter- 
rupted suture  has  been  used  and  the  wound  becomes  sep- 
tic, all  that  is  necessary  is  to  remove  a  stitch  or  two 
and  put  in  a  small  rubber  tissue  drain.  Whereas  if  a 
continuous  suture  has  been  used,  the  only  stitch  present 
must  be  removed,  and  the  wound  gapes  open.     This  is 


SUTURING  WOUNDS 


293 


just  another  example  of  the  folly  of  putting  all  of  one's 
eggs  in  one  basket. 

Intfacuticular  and  Subcuticular  Stitches. — The  in- 
tracuticular  stitch  is  continuous,  and  is  open  to  the 
same  criticism.  It  is  accom- 
plished by  taking  the  ' '  bites ' ' 
within  the  true  skin  on  its 
cut  margin.  No  perforations 
are  made  on  the  surface  and 
as  a  result  the  suture  is  en- 
tirely buried  except  at  the 
points  of  entrance  and  exit. 
The  subcuticular  stitch  is  ac- 
complished in  the  same  way 
except  that  the  "bites"  are 
in  the  subcutaneous  tissue. 

Interrupted  Sutures. — 
For  general  work,  the  inter- 
rupted is  superior  to  all  the 
others  and  is  the  one  which 
should  be  used.  The  needle 
should  enter  the   skin  in  a 

plane  at  right  angles  to  the  plane  of  the  skin ;  only  enough 
tissue  should  be  included  in  the  "bite"  to  insure  a  firm 
grip;  the  suture  should  be  drawn  only  taut  enough  to 

hold  the  skin  edges  in  approxima- 
tion. If  more  tissue  is  included 
on  one  side  than  on  the  other,  one 
skin  edge  will  rise  above  the  other 
and  the  result  will  be  delayed 
union  and  an  irregular  scar.  If 
too  much  tissue  is  included  in 
the  bite  or  if  the  suture  is  drawn  too  tightly,  the  nutrition 
of  the  part  is  impaired  and  necrosis,  infection  and  de- 
laved  healing  result. 


Fig.  120. — The  Intracutaneous  or 
Subcuticular  Suture.  (Hal- 
sted.) 


Fig.   121 

TURE. 

ettc.) 


— INTERRUPTED    Su- 

(Bemard  and   IIu- 


294      SURGICAL  TECHNIC  AND  BANDAGING 

DRESSING 

The  way  in  which  the  wound  shall  he  dressed  depends 
upon  the  character  of  the  wound,  its  size,  location  and 
whether  it  is  to  be  drained  or  not.  Small,  clean  wounds 
which  have  been  sewed  up  without  drainage,  require  only 
a  few  layers  of  dry  sterile  gauze  held  in  place  by  a  band- 
age, by  adhesive  plaster,  or  by  a  collodion  cocoon. 
Wounds  from  which  there  is  considerable  discharge  must 
be  protected  by  a  more  voluminous  dressing.  Septic 
wounds  may  be  treated  either  with  dry  or  wet  sterile 
dressings. 

Wet  Dressing". — By  a  wet  dressing  is  meant  a  gauze 
dressing  saturated  with  an  antiseptic  solution,  such  as 
bichlorid  of  mercury,  alcohol,  chlorinated  soda,  etc.  In 
this  way  the  discharge  is  kept  moist,  and  does  not  get 
a  chance  to  coagulate  and  so  impede  the  drainage.  The 
great  conflict  now  going  on  in  Europe  is  responsible  for 
the  development  of  the  most  effective  solution  yet  devised 
for  the  treatment  of  septic  wounds,  that  is  Dakin's  solu- 
tion. 

Dakin's  Solution.— When  using  this  solution  by  means 
of  the  Carrel  technic,  by  which  every  part  of  the  wound 
is  kept  continuously  irrigated,  a  septic  wound  quickly 
becomes  sterile  so  that  it  may  be  sutured  just  as  though 
it  were  a  fresh  clean  wound.  The  personal  experience 
of  the  writer  has  been  limited  to  ambulatory  out-patient 
eases,  in  which  the  elaborate  Carrel  technic  could  not 
be  carried  out,  but  the  results  obtained  by  using  the  so- 
lution simply  in  the  form  of  a  wet  dressing  have  been 
such  as  to  give  it  preference  to  all  others. 


BANDAGES 

Application. — A  roller  bandage  is  a  strip  of  material 
rolled  upon  itself  in  such  a  way  as  to  form  a  compact 


BANDAGES  295 

body.  Its  free  end  is  called  the  initial  extremity;  its 
other  end,  that  is,  the  end  which  is  in  the  center  of  the 
roller,  is  known  as  the  terminal  extremity.  The  sur- 
face of  the  bandage  which  is  in  sight  when  it  is  entirely 
rolled  is  called  the  external  surface;  the  other  is  the  in- 
ternal. In  applying  a  bandage,  the  terminal  extremity 
should  be  grasped  in  the  left  hand  and  the  roller  in  the 
right,  the  external  surface  always  being  applied  toward 
the  skin.  As  the  bandage  is  then  carried  about  the  part, 
it  unwinds  itself  into  the  hand  and  does  not  tend  to  be 
jerked  onto  the  floor. 

Material. — Bandages  may  be  made  of  any  flexible  ma- 
terial, such  as  gauze,  flannel,  elastic  webbing,  rubber,  and 
so  forth.  Gauze  is  the  material  in  common  use  except  for 
some  special  purpose.  The  functions  of  a  bandage  are  to 
retain  dressings  in  place,  to  render  support  to  a  part,  or 
to  make  compression.  A  bandage  should  be  applied 
firmly  enough  so  that  it  does  not  tend  to  slip  off.  Only 
enough  pressure  should  be  applied  to  accomplish  this, 
since  excessive  pressure  might  interfere  seriously  with 
the  blood  supply  of  the  part  and  result  in  destruction 
of  the  tissues. 

Bandages  of  the  Head 

Horizontal  Circular.— This  is  the  simplest  type  of 
bandage  and  means  that  the  bandage  is  carried  around 
the  head  in  a  horizontal  plane.  It  has  very  limited  use 
and  is  apt  to  become  loose. 

Figure-of -Eight.— This  bandage  is  useful  for  holding- 
dressings  or  maintaining  compression  on  the  vertex  of 
the  head.  It  is  applied  as  follows :  the  initial  extremity 
of  the  bandage  is  placed  on  the  vertex;  the  roller  is  car- 
ried downward- in  front  of  the  right  ear,  under  the  chin 
and  upward  in  front  of  the  left  ear  to  the  starting  point ; 
next  it  passes  behind  the  right  ear,  under  the  occiput, 
behind  the  left  ear  to  the  vertex  again.    This  completes 


•Jiili       SURGICAL  TKOILNLO  AND  MAND  AGING 


one  turn  of  the  bandage  and  as  many  may  be  applied  as 
is  necessary. 

Recurrent  or  Melon  Bandage.— This  bandage  is  started 
in  the  middle  of  the  forehead  and  the  first  layer  is  car- 
ried back  to  a  point  below  the  external  occipital  pro- 
tuberance. Then  the  bandage  is  reversed  and  carried 
back  to  the  forehead,  overlapping  the  first  layer  by  one 
half  its  width.     These  turns  are  continued,  overlapping 

first  on  one  side  and  then 


Fig.  122. — Recurrent  Bandage  of 
the  Head. 


on  the  other,  until  the 
whole  scalp  is  covered. 
Two  or  three  circular 
turns  about  the  head  then 
will  anchor  the  whole  and 
hold  it  in  place. 

Figure-of-Eight  of  One 
Eye  or  Monocular  Band- 
age.—This  starts  with  a 
horizontal  circular  turn 
about  the  forehead,  above 
the  ears,  and  across  the 
occiput.  The  next  turn 
passes  across  the  occiput 
and  under  the  ear;  then  upward  over  the  eye  to  the  fore- 
head again.  These  turns  are  continued  until  the  part 
is  sufficiently  protected. 

The  Binocular  Bandage  or  Figure-of-Eight  of  Both 
Eyes.— This  is  applied  in  the  same  way,  covering  first 
one  eye  and  then  the  other. 

Four-Tailed  Bandage. — This  is  the  simplest  form  of 
bandage  applicable  to  the  lower  jaw.  It  is  useful  for 
retaining  dressings  or  for  temporarily  maintaining  frac- 
tures of  the  mandible.  It  may  be  made  of  any  kind  of 
cloth  that  is  at  hand.  A  strip  of  material  three  inches 
wide  by  one  yard  long  is  necessary.  This  is  split  up  to 
within  four  or  five  inches  of  the  center,  making  the  so- 
called  tails.     The  central  or  unsplit  part  of  the  bandage 


BANDAGES 


297 


Fig.  123.— Crossed  Ftg- 
ure-of-eight  bandage 
of  Both  Eyes. 


is  now  placed  under  the  chin.  The  two  tails  which  rep- 
resent the  lower  half  of  the  bandage  are  brought  up- 
ward, one  on  each  side,  and  tied  at  the  top  of  the  head. 
The  other  two  tails  are  tied  under 
the  occiput.  The  ends  remaining 
after  tying  these  two  knots  are  then 
tied  together.  The  amount  of  force 
applied  can  be  varied  at  will.  By- 
tying  the  knot  at  the  vertex  more 
tightly,  a  greater  upward  pull  is 
given  to  the  mandible;  a  greater 
backward  pull  is  obtained  by  tight- 
ening up  on  the  knot  under  the  occi- 
put. The  two  ends  tied  across  the 
top  of  the  head  hold  the  dressing  in 
place. 

Barton's  Bandage.— This  is  the 
most  useful  bandage  there  is  for  injuries  and  diseases  of 
the  lower  jaw.  It  is  applied  as  follows:  the  initial  ex- 
tremity is  placed  on  the  top  of  the  head,  the  bandage  is 

carried  downward  behind 
the  left  ear,  then  directly 
across  the  neck  under  the 
external  occipital  protu- 
berance, then  forward  un- 
der the  right  ear,  across 
the  cheek,  in  front  of  the 
chin,  and  backward,  under 
the  left  ear  to  the  occiput. 
From  there  it  is  carried 
upward  behind  the  right 
ear  to  the  starting  point. 
So  far,  then,  one  has  ap- 
plied a  figure-of-e  i  g  h  t 
bandage  one  loop  of  which  encircles  the  head  and  the 
other  chin  and  neck.  Continuing,  the  bandage  is  carried 
downward  in  front  of  the  right  ear,  under  the  chin,  up- 


Fig.  124. — Barton's  Bandage,  or 
Figure-of-eight  of  the  Jaw. 


298      SURGICAL  TECITNIC  AND  BANDAGING 

ward  in  front  of  the  left  ear  to  the  starting  point.  This 
completes  one  turn  of  the  bandage  and  must  be  reinforced 
by  several  others.  This  dressing  can  be  further  strength- 
ened by  applying  safety  pins  at  the  intersecting  points. 


Fig.  125. — The  Four-tailed  Bandage.  Tying  the  final  knot  exerts  pressure 
upon  the  chin,  both  upward  and  backward.  (Foote's  "Minor  Sur- 
gery.") 

Gibson's  Bandage.— This  is  also  intended  for  injuries 
of  the  lower  jaw,  but  is  neither  as  effective  nor  as  easy 
of  application  as  either  the  four-tailed  or  the  Barton 
bandage.  It  consists  of  three  series  of  loops :  one  hori- 
zontal, about  the  brow  and  occiput;  one  vertical,  about 
the  chin  and  the  top  of  the  head;  one  oblique,  passing 
in  front  of  the  chin  and  around  the  back  of  the  neck. 


CHAPTER  XI 

QENERAL    ANESTHESIA,    ITS    PHARMACOLOGY    AND 
ADMINISTRATION 

Freeman  Allen,  M.D. 

HISTORY  OF  ANESTHESIA 

Gas.— In  December,  1844,  Dr.  Horace  Wells,  a  dentist 
of  Hartford,  Coim.,  discovered  the  use  of  nitrous  oxid  gas 
as  an  anesthetic  in  the  extraction  of  teeth.  He  allowed 
one  of  his  colleagues  to  administer  gas  to  him  while 
he  had  a  tooth  pulled  and  found  the  process  entirely  pain- 
less. In  the  same  year  Wells  attempted  to  administer 
gas  at  the  Harvard  Medical  School,  but  probably  se- 
lected a  difficult  subject.  He  selected  a  full-blooded  pa- 
tient who  was  difficult  to  control;  in  consequence  his  ad- 
ministration proved  a  fiasco,  and  he  became  an  object  of 
public  ridicule.  This  experience,  no  doubt,  tended  to  af- 
fect his  mind.  Both  Wells  and  Morton,  the  pioneers 
in  anesthesia,  died  showing  symptoms  of  mental  aber- 
ration. It  is  highly  probable  that  this  result  was  brought 
about  by  their  repeated  use  of  anesthetics  in  the  course 
of  their  experiments. 

Ether. -On  September  20th,  1846,  Dr.  W.  T.  G.  Mor- 
ton, a  dentist  of  Boston,  employed  the  vapor  of  ether  to 
produce  general  anesthesia  in  a  patient  at  the  Massa- 
chusetts General  Hospital  and  thereafter  administered  it 
in  cases  requiring  surgical  operation,  with  complete  suc- 
cess. This  great  achievement  marked  a  new  era  in  sur- 
gery. Operations  were  performed  in  America  in  nu- 
merous instances  under  ether  inhalation,  the  result  being 

299 


.300    GENERAL  ANESTHESIA— PHARMACOLOGY 

only  to  establish  more  firmly  its  value  as  a  successful 
anesthetic. 

Chloroform. — The  anesthetic  properties  of  chloroform 
were  discovered  in  1847  by  Simpson  of  Edinburgh.  This 
was  at  first  supposed  to  be  a  better  anesthetic  than  ether, 
because  it  was  more  agreeable  to  use  and  it  was  employed 
freely;  but  finally,  when  patients  began  to  die  from  its 
use,  it  became  evident  that  it  was  not  a  safe  anesthetic. 
The  use  of  chloroform  was  thought  so  unsafe  and  it  was 
so  difficult  to  administer  that  the  English  medical  profes- 
sion began  to  devote  more  time  to  the  search  for  some- 
thing that  might  take  its  place.  As  a  consequence,  anes- 
thetics came  to  be  used  more  in  England  than  in  this 
country.  Chloroform  use.d  to  kill  patients,  therefore 
they  set  about  devising  apparatus  for  increasing  the 
safety  of  chloroform,  and  a  great  many  kinds  of  these 
devices  came  over  from  England ;  but,  of  course,  as  usual, 
when  this  country  finally  did  take  up  the  administration 
of  anesthetics,  we  far  outstripped  anything  that  Eng- 
land had  done  in  that  line.  So  much  of  that  for  a  brief 
historical  mention  of  the  anesthetics,  gas,  ether  and 
chloroform. 


PREPARATION  OF  PATIENTS  FOR  ANESTHESIA 

Emptying  of  Viscera.— A  word  will  be  said  here  about 
the  preparation  of  patients  for  inhaling  anesthetics.  Ex- 
cept in  the  brief  administrations  of  dentistry,  patients 
should  come  to  an  operation  with  an  empty  stomach, 
an  empty  rectum  and  an  empty  bladder.  No  prolonged 
and  profound  administration  of  any  anesthetic  should 
take  place  in  a  patient  who  has  not  been  previously  pre- 
pared. 

The  degrees  of  starving  and  purging  which  a  patient 
should  undergo  vary  with  the  patient.  A  weak  patient 
in  being   prepared   should   not   be   starved    or   heavily 


PHYSIOLOGY  OF  ANESTHESIA  301 

purged.  An  athletic,  strong,  full-blooded  man  should  be 
thoroughly  purged  or  given  very  little  food  for  a  day  or 
two  before  the  operation,  in  order  to  bring  him  more 
easily  under  the  influence  of  the  anesthetic. 

Morphin  as  a  Preliminary.— For  prolonged  adminis- 
trations the  patients  do  much  better  from  every  point 
of  view  by  having  a  preliminary  injection  of  morphin, 
and  the  dose  should  vary  in  proportion  to  the  bodily 
weight  and  general  conformation  of  the  patient.  Sup- 
pose that  one  is  dealing  with  a  big,  heavy,  two  hun- 
dred pound  man,  whom  it  is  wished  to  place  under  pro- 
found anesthesia.  That  man  must  be  quieted  with  mor- 
phin to  lessen  the  amount  of  ether  necessary  to  control 
him.  Now  a  man  weighing  200  lbs.  could  easily  take  half 
a  grain  of  morphin,  especially  if  he  uses  alcohol  or  to- 
bacco. Therefore,  for  a  big  man,  the  dose  of  morphin 
would  vary  from  a  quarter  to  half  a  grain,  and  the  dose 
of  atropin  from  one  one-hundredth  to  one  one-hundred- 
and-fiftieth  grain;  for  a  patient  of  average  size,  weigh- 
ing 150  lbs.,  a  sixth  to  a  quarter  grain  of  morphin,  and 
one  two-hundredth  to  one  one-hundred-and-fiftieth  grain 
of  atropin ;  for  a  patient  weighing  100  to  125  lbs.,  a  tenth 
of  a  grain  of  morphin  to  a  sixth  and  one  two-hundredth 
grain  of  atropin. 

There  are  several  reasons  for  giving  the  morphin.  In 
the  first  place,  it  calms  the  patient  and  lessens  any  sense 
of  fear.  It  also  lessens  the  amount  of  ether,  gas  or 
chloroform  necessary  to  control  the  patient.  Atropin 
dries  up  mucus  and  saliva,  and  this  with  the  morphin  acts 
as  a  safeguard  against  pneumonia. 


PHYSIOLOGY  OF  ANESTHESIA 

The  physiology  of  anesthesia  is  now  considered.  The 
ether,  in  order  to  be  effective  in  the  patient,  must  enter 
the  blood  stream  in  some  way.    There  are  various  ways 


302     GENERAL  AXESTII  KSIA      N  IA  k\\I  ACM  )LO(JY 

of  introducing  ether  vapor  into  the  blood  stream.  One 
can  open  a  vein  and  inject  the  salt  solution  of  ether  and 
thus  induce  anesthesia,  or  one  can  carefully  clean  the 
rectum  and  inject  an  emulsion  of  oil  of  ether  into  the 
rectum  and  the  patient  will  become  unconscious;  one  can 
introduce  a  solution  of  ether  into  the  stomach — make  the 
patient  drink  ether — and  get  anesthesia  that  way ;  but,  of 
course,  to  administer  ether  in  that  way  injures  the  mu- 
cous membrane  of  the  stomach  or  of  the  rectum.  Ether 
can  be  given  by  the  rectum,  but  it  is  difficult  to  control. 
It  has  been  found  that  the  lungs  are  the  most  convenient 
channel  for  the  administration  of  ether.  The  principal 
thing  is  the  effect  of  the  ether  on  the  respiration.  The 
effect  of  all  anesthetics  is  first  to  stimulate,  then  to  de- 
press, and  finally  to  paralyze  the  respiration.  If  a  pa- 
tient is  given  gas,  the  respiration  increases.  If  after  a 
while  he  is  given  more  gas,  the  respiration  tends  to  de- 
crease ;  and  if  he  is  still  given  gas,  the  organs  of  respira- 
tion will  finally  become  paralyzed.  The  same  is  true  with 
ether,  and  with  chloroform,  although  the  use  of  chloro- 
form is  much  more  dangerous. 

Comparative  Safety  of  Anesthetics.— That  leads  to  the 
subject  of  the  safety  of  these  different  anesthetics.  It 
must  be  asked  "What  are  the  death  rates  resulting  from 
the  use  of  gas,  ether  and  chloroform?"  Gas,  as  ordina- 
rily administered,  is  the  safest  known  anesthetic.  The 
death  rate  is  so  small  that  no  actual  estimate  has  been 
made. 

Death  Rates  from  Gas,  Ether  and  Chloroform.— The 
death  rate  from  gas  (N20)  is  about  one  in  two  hundred 
and  fifty  thousand;  that  from  ether  (C2H5)20  is  about 
one  in  sixteen  thousand;  that  from  chloroform  (CHC13) 
is  about  one  in  every  three  thousand.  Gas  is  safest  when 
limited  to  dental  administration.  This  statement  is  not 
true  of  the  prolonged  administration  of  gas.  For  sur- 
gical purposes  it  is  a  very  dangerous  anesthetic.  Next 
comes  ether.    Last  conies  chloroform.    Chloroform  is  five 


ADMINISTRATION  OF  ANESTHETICS      303 

times  more  dangerous  than  ether  and  a  great  deal  more 
dangerous  than  gas.  Somnoform  and  ethyl  chlorid  are 
about  the  same  as  ether.  Of  course,  chloroform  is  un- 
safe anyway,  notably  unsafe  in  dentistry,  because  the 
danger  in  chloroform  comes  in  the  light  degree  of  chloro- 
form anesthesia.  When  a  patient  is  lightly  under  the 
influence  of  chloroform,  that  is  the  time  when  he  is  most 
in  danger.  Therefore  chloroform  is  notably  dangerous 
in  any  operation  about  the  mouth  or  throat. 


PRACTICAL  ADMINISTRATION  OF  ANESTHETICS 

Exclusion  of  Air.— In  regard  to  the  practical  adminis- 
tration of  these  anesthetics,  it  must  be  stated  that  all 
are  volatile  except  chloroform.  Being  volatile,  they  are 
difficult  to  keep  in  the  lungs.  The  difficulty  is  to  control 
the  patient.  Air  limitation  is  a  most  important  principle 
in  the  administration  of  a  volatile  anesthetic.  A  cylinder 
of  nitrous  oxid  gas  in  liquid  form  and  under  pressure 
becomes  gaseous  when  liberated.  One  might  hold  that 
gas  in  front  of  his  face  all  day  and  he  would  get  no 
effect  because  of  the  air.  On  the  other  hand,  if  he  put 
the  container  into  his  mouth,  he  would  be  inhaling  gas, 
because  the  air  would  be  cut  off.  The  air  must  be  ex- 
cluded in  order  to  make  the  gas  effective. 

The  simplest  way  of  excluding  air  is  to  close  the 
mouth  and  close  the  nose.  Unfortunately,  there  are  other 
exigencies  which  require  different  methods.  In  a  great 
many  cases  a  big  tube  goes  into  the  mouth,  the  patient 
inhales  fully  and  the  surgeon  operates  in  the  period  of 
available  anesthesia.  That  period  of  available  anesthesia 
varies  in  different  cases.  It  may  last  only  from  twenty- 
five  to  forty  seconds.  That  is  a  very  short  available 
anesthesia.  If  a  full  dose  of  nitrous  oxid  gas  is  given, 
the  operator  has  about  twenty-five  to  forty-five  seconds 
to  operate  in.     On  the  other  hand,  the  effect  of  somno- 


304    GENERAL  AX  EST  1 1 ESIA— PHAEMACOLOGY 

form  lasts  much  longer.  Somnoform  lasts  after  its  with- 
drawal, from  fifty  seconds  to  a  minute  and  a  half. 

Metal  Face-Piece.— An  apparatus  for  giving  gas  is  nec- 
essary if  one  wishes  to  administer  gas  with  a  face- 
piece.  This  is  surmounted  by  a  gas  chamber.  This  gas 
chamber  contains  an  inspiratory  valve  and  an  expiratory 
valve,  fitted  with  a  pneumatic  rubber  face-piece,  of  which 
there  are  several  sizes  to  fit  various  sized  faces.  If  a 
patient  has  a  small  face,  it  would  be  absurd  to  use  a  big 
face-piece,  because  everything  dej tends  on  the  size  of  the 
face-piece.  The  face-piece  should  fit  the  patient's  face 
up  to  the  bridge  of  his  nose  and  come  down  to  the  chin. 
The  object  of  the  face-piece  is  to  exclude  air  and  every- 
thing depends  upon  the  correct  limitation  of  air.  If  one 
tries  to  administer  gas  with  a  face-piece  that  does  not 
fit,  he  will  get  a  failure.  It  takes  a  great  deal  of  ex- 
perience to  get  it  properly. 

Gas  Inhaling. — In  gas  inhaling  the  patient  breathes 
gas  from  a  bag  through  the  inspiratory  valve  down  into 
his  lungs,  and  gas  plus  air  goes  out  through  the  expira- 
tory valve.  The  practical  result  is  that  in  from  one 
minute  to  a  minute  and  a  half  or  two  minutes,  according 
to  the  degree  of  air  limitation,  the  patient  will  show  signs 
of  gas  anesthesia.  If  the  face-piece  does  not  fit  or  if  air  is 
let  in,  the  administration  is  delayed,  and  the  result  is  im- 
perfect anesthesia,  and  the  patient  becomes  exhausted  be- 
cause he  is  only  partially  under  the  influence  of  the  an- 
esthetic. 

Simple  Administration  of  Gas.— A  description  of  the 
simple  administration  of  gas  is  here  given.  The  patient 
is  placed  on  the  operating  table  and  gas  administered  in 
a  cylinder.  The  patient  breathes  through  valves  for  two 
or  three  minutes,  after  which  symptoms  of  gas  anesthesia 
will  appear.  The  first  symptom  is  a  change,  an  increase 
in  the  rate  and  depth  of  respiration,  which  finally  be- 
comes stertorous,  and  this  is  a  sure  sign  that  the  patient 
is  under  the  anesthetic.    If  the  anesthesia  is  pushed  be- 


ADMINISTRATION  OF  ANESTHETICS      305 

yond  that  stage,  cyanosis  results ;  if  still  further,  the  res- 
piration will  increase  in  rate  and  depth;  if  still  further, 
the  patient  will  stop  breathing-,  as  a  result  of  paralysis 
of  the  respiratory  center.  If,  when  the  patient  is  under 
the  anesthetic,  air  is  pumped  in  that  brightens  the  pa- 
tient up ;  he  will  show  signs  of  recovery  and  the  respira- 
tion will  return  to  normal.  If  respiration  is  stimulated 
by  gas  or  by  ether,  when  the  stimulus  is  removed  the 
respiration  will  return  to  normal. 

Ether  Administration,— In  the  administration  of  ether 
the  same  idea  holds  good.  Ether,  of  course,  is  volatile, 
but  it  is  not  so  volatile  but  that  it  can  be  administered 
by  the  open  method,  a  method  which  allows  large  amounts 
of  air  to  gain  access  to  the  patient's  lungs. 

Methods  of  Administering  Ether. — The  following  are 
the  different  methods  of  administering  ether:  (a)  1,  open, 
2,  semi-open,  3,  closed  (according  to  the  limitation  of 
air) ;  (b)  rectal;  (c)  intravenous;  (d)  intertracheal.  The 
latter  are  simply  fancy  methods. 

Open. — Ether  by  the  open  method  would  be  adminis- 
tered by  the  chloroform  mask.  The  ether  is  dropped 
gradually  until  anesthesia  is  obtained.  Another  form  of 
administration  under  the  open  method  is  the  use  of  an 
open  inhaler,  of  which  the  simple  cone  is  the  best  known. 
That  is,  a  cone  is  made  to  fit  the  face. 

Semi-open. — The  semi-open  method  is  so  called  because 
some  attempt  is  made  to  limit  air. 

Closed. — The  closed  method  of  giving  ether  is  a  method 
which  provides  for  the  maximum  limitation  of  air.  One 
can  suppose  that  an  inhaler  is  fitted  for  the  inhalation  of 
ether.  It  may  be  stuffed  with  gauze  and  the  patient 
breathes  to  and  fro  into  a  rubber  bag.  In  that  way,  the 
patient  gets  no  air  or  just  as  much  air  as  is  allowed 
occasionally.  This  is  another  illustration  of  the  all- 
important  principle  of  limiting  air.  Volatile  anesthetics 
cannot  be  given  successfully  in  the  presence  of  air. 

Of  the  foregoing,  the  open  method  is  more  liable  to  pro- 


306    GENERAL  ANESTHESIA— PHARMACOLOGY 

duce  pneumonia  for  this  reason.  In  the  open  method  of 
administering  ether  there  is  Tree  access  of  air,  and  this  is 
administered  on  a  gauze  at  the  entrance  of  the  lungs. 
After  the  administration,  frost  appears  on  the  gauze. 
That  cold  chills  the  lungs.  Of  the  three  methods  it  is 
the  most  liable  to  be  accompanied  by  bronchitis  and  pneu- 
monia. For  this  reason  the  open  method  seems  utterly 
impracticable.    It  does  not  control  the  patient  at  all. 

Dangerous  Symptoms  in  Ether  Administration.— These 
are  failure  of  the  respiration,  characterized  by  short, 
jerky  inspiration  and  prolonged  expiration  which  indi- 
cates an  over-dose  of  ether,  associated  with  wide  dila- 
tation of  the  patient's  pupils  which  do  not  react  to  light; 
the  corneal  reflex  is  absent.  The  most  important  eye 
reflex  to  go  by  is  the  corneal;  the  pupillary  reflex  is 
only  useful  taken  in  conjunction  with  other  signs.  With 
the  corneal  reflex  present  the  patient  is  not  too  deeply 
under ;  if  absent,  the  patient  is  too  deeply  under  anesthe- 
sia. If  the  patient  winks  when  the  cornea  is  touched  the 
corneal  reflex  is  present. 

Chloroform.— To  return  to  the  practical  administration 
of  these  anesthetics :  volatile  anesthetics  must  be  given 
with  limitation  of  air,  but  that  is  not  true  of  chloroform, 
which  is  not  volatile.  Chloroform  is  a  heavy,  bulky 
vapor  which  tends  to  lurk  down  in  the  lower  part  of  the 
lungs.  Chloroform  must  always  be  given  by  the  open 
method.  Limitation  of  air  with  chloroform  will  kill  the 
patient.  It  must  always  be  administered  with  a  great 
dilution  of  air. 

Apnea 

Apnea  means  the  stoppage  of  breathing,  and  the  causes 
and  treatment  of  it  are  numerous.  The  causes  of  it  vary 
with  the  anesthetic.  If  a  patient  stops  breathing  under 
nitrous  oxid,  the  cause  is  probably  paralysis  of  the  res- 
piratory center;  if  under  ether,  it  is  also  paralysis;  if 
under  chloroform,  it  is  probably  partly  paralysis,  but 


ADMINISTRATION  OF  ANESTHETICS      307 

with  a  distinct  cardiac  element  in  it.  In  other  words, 
the  heart  stops  simultaneously  with  the  respiration.  The 
treatment  is  the  same  in  all  cases,  namely,  artificial  res- 
piration. 

Sylvester's  Method  of  Artificial  Respiration.— If  the 
patient  has  stopped  breathing  the  first  thing  to  do  is  to 
make  sure  that  the  mouth  is  open,  that  the  tongue  is 
forward,  and  that  the  air  can  enter  the  lungs  if  it  gets 
a  chance.  It  is  necessary  to  always  open  the  mouth 
and  draw  forward  the  tongue.  Then  respiration  is  imi- 
tated. The  gas,  ether  or  chloroform  is  forced  out  of 
the  lungs.  Simple  pressure  of  the  thorax  will  expel  the 
gas  or  other  anesthetic  from  the  lungs  and  start  respira- 
tion. Then  inspiration  is  slowly  instituted  by  drawing 
the  arms  above  the  head,  and  expiration  by  drawing 
them  down.  This  method  of  artificial  respiration  is 
known  as  Sylvester's  method  and  is,  in  the  writer's  opin- 
ion, the  best  known  method  of  restoring  respiration. 
Pulmotors  and  other  mechanical  devices  for  promoting 
respiration  are  not  so  efficient  as  the  Sylvester  method. 
That  was  pointed  out  very  clearly  by  Professor  Hen- 
derson of  Yale  in  a  recent  paper.  This  method  should 
be  tried  even  if  the  patient  looks  absolutely  dead.  To 
hurry  does  no  good,  and  may  even  do  the  greatest  harm. 
The  method  must  be  done  deliberately  and  quietly,  not 
more  than  sixteen  times  a  minute.  Ribs  have  been 
broken,  and  other  trauma  has  been  caused  by  students 
who  have  thumped  patients  on  the  stomach  and  nearly 
killed  them.  In  the  proper  procedure  the  elbows  are 
grasped  and  the  thorax  pressed,  and  that,  more  often 
than  not,  may  be  sufficient  to  initiate  automatic  res- 
piration ;  but  in  some  cases  it  will  not.  If  not,  the  arms 
are  brought  up,  then  gently  down  again,  pressing  the 
thorax  and  raising  the  arms  above  the  head  slowly. 
This  is  most  important.     Hurry  accomplishes  nothing. 

Causes  of  Apnea.— In  the  case  of  ether  the  patient 
stops  breathing  from  paralysis  of  the  respiratory  center 


308    GENERAL  ANESTHESIA— PHARMACOLOGY 

from  over-dose  of  the  ether.  In  chloroform  anesthesia 
the  patient  stops  breathing  from  dilatation  of  the  heart 
combined  with  paralysis  of  the  respiratory  center.  The 
treatment  is  the  same  in  all  cases,  namely,  properly  per- 
formed artificial  respiration,  which  was  spoken  of  above. 
Origin  of  Symptoms. — As  has  been  said,  ether  is  not 
dangerous,  relatively  speaking ;  if  there  is  a  danger,  it  is 
from  an  over-dose  causing  a  paralysis  of  the  respiratory 
center.  Chloroform,  on  the  other  hand,  is  dangerous,  be- 
cause it  is  a  dilater  of  muscle  tissue ;  it  dilates  the  heart 
and  the  muscular  coat  of  the  arteries.  The  dangers  of 
nitrons  oxid  are  comparatively  few;  indeed  when  used  in 
dentistry  it  is  perfectly  safe;  when  used  in  surgery,  pro- 
longed inhalations  are  exceedingly  dangerous,  and  the 
death  rate  of  nitrous  oxid  and  oxygen  used  in  surgery 
would  surpass  that  of  chloroform.  The  dangers  of  cocain 
are  very  well  known.  It  is  a  very  toxic  drug  and  easily 
brings  trouble.  Novocain,  on  the  other  hand,  is  abso- 
lutely non-toxic,  and  large  quantities  can  be  used  with- 
out danger. 

Symptoms  of  Hemorrhage  and  Shock 

Hemorrhage.— This  subject  may  be  considered  here  in 
relation  to  anesthesia.  The  symptoms  of  hemorrhage  are 
of  course,  first,  blanching.  A.  patient,  previously  of  good 
color,  will  become  white;  then  the  pulse  increases,  from 
80  to  150  or  160,  and  becomes  thready.  The  patient  will 
have  a  sighing  respiration ;  that  is  air  hunger,  indicating 
a  desire  for  oxygen.  He  will  be  cold  to  the  touch  instead 
of  warm.  The  principal  symptom  of  hemorrhage  is  the 
marked  increase  in  the  rate  and  diminution  in  volume 
of  the  pulse. 

Shock.— In  differentiating  shock  from  hemorrhage  the 
previous  course  of  the  operation  should  be  considered. 
The  symptoms  are  a  gradual  failing  of  the  pulse  not 
suddenly  but  slowly.    It  becomes  not  necessarily  rapid  as 


ADMINISTRATION  OF  ANESTHETICS      309 

in  hemorrhage,  but  very  feeble  and  poor,  from  lowering 
of  the  blood  pressure.  The  patient  becomes  pale,  sweats 
and  feels  cold  and  clammy.  In  other  respects  symptoms 
of  shock  occur  during  operations.  In  traumatic  injuries 
the  patient  comes  to  the  operating  room  a  pale  gray  in 
color,  cold  and  with  a  feeble  pulse,  feeble  voice  and 
obviously  in  a  condition  of  shock. 

Acapnea 

Rebreathing.— This  condition  is  a  deprivation  of  car- 
bondioxid  from  the  system  and  is  seen  in  certain  admin- 
istrations of  gas  and  oxygen  where  very  rapid  breathing 
is  induced  without  rebreathing,  and  the  patient  exhausts 
the  supply  of  carbondioxid  necessary  to  maintain  res- 
piration. That  is  the  reason  why  rebreathing  is  desir- 
able ;  that  is  to  say,  if  the  patient  rebreathes  into  a  bag 
he  conserves  carbondioxid  which  is  a  respiratory  stimu- 
lant and  is  necessary  for  the  proper  performance  of 
respiration.  Acapnea,  then,  is  the  body's  necessity  for 
a  restoration  of  a  normal  supply  of  carbondioxid. 

The  above  are  the  important  points  to  be  remembered 
in  the  discussion  of  anesthesia.  There  is  no  need  of 
accidents  if  the  properly  educated  anesthetist  observes 
the  proper  caution;  but  if  accidents  do  occur,  as  they 
sometimes  do,  correct  artificial  respiration,  etc.,  will 
usually  prevent  fatality.  The  foregoing  facts  are  clearly 
stated  and  if  thoroughly  mastered  should  enable  the 
dentist  to  put  them  into  successful  practice. 


CHAPTER   XII 

MILITARY  ROENTGENOLOGY  FOR  DENTISTS 
Frederick  William  O'Brien,  M.D. 

DENTAL  WORK  AND  ROENTGENOLOGY  IN  WAR 

Despite  the  innate  dread  of  war  and  all  that  is  carried 
in  its  train  one  must  recognize  that  this  war  by  the 
United  States  has,  among  other  good  things,  obliged 
proper  recognition  of  the  dental  profession  and  of  the 
science  of  roentgenology  by  the  Medical  Department 
of  the  United  States  of  America.  The  need  has  always 
been  felt  by  the  Surgeon  General,  but  authority  and 
money  were  lacking  until  now  to  adequately  expand  these 
two  intimately  associated  branches  of  medicine.  The 
Surgeon  General  has  now  established  schools  of  mili- 
tary roentgenology  throughout  the  country  at  which  are 
being  trained  picked  medical  officers,  of  both  sea  and  land 
forces,  who  will  act  as  roentgenologists  at  the  various 
base  hospitals  of  the  army  and  navy,  whether  these  are 
located  in  the  field  or  at  training  camps.  These  special- 
ists will  be  available  for  consultation  by  the  now  much 
enlarged  dental  corps  of  the  Medical  Department. 

During  Mexican  border  service  of  the  writer  for  six 
months  at  El  Paso,  there  was  an  X-ray  apparatus  at 
the  Base  Hospital  in  charge  of  an  enlisted  man.  There 
were  approximately  50,000  troops  dependent  upon  this 
service  at  all  times.  The  situation  was  such  that  when 
a  difficult  case  came  up  for  diagnosis  the  roentgen  con- 
clusions were  not  dependable. 

310 


DISCOVERY  OF  ROENTGEN  RAYS         311 

In  the  present  war,  while  some  members  of  the  dental 
corps  will  be  in  the  advanced  zone  to  care  for  emergen- 
cies, the  major  portion  of  the  work  will  be  done  by  the 
dental  corps  out  of  the  zone  of  danger,  where  there  will 
be  adequate  apparatus  and  competent  roentgenologists. 

It  has  not  been  possible  for  the  government  to  supply 
a  specific  type  of  apparatus  and  accessories  for  use  by 
its  roentgenologists,  but  generically  all  are  the  same. 
Some  form  of  interrupterless  transformer  of  standard 
manufacture  will  be  used.  While  switchboards  and  un- 
essential matters  may  differ,  basically  all  are  built  and 
operated  upon  the  same  principles  and  the  government 
roentgenologists  are  being  instructed  accordingly. 


DISCOVERY  OF  ROENTGEN  RAYS 

Professor  William  Conrad  Roentgen  of  Wiirzburg,  Ba- 
varia, rather  accidentally  discovered  in  the  autumn  of 
1895  the  rays  which  now  bear  his  name.  He  was  experi- 
menting with  what  had  been  up  to  that  time  practically 
nothing  more  than  a  plaything  of  scientists,  the  so-called 
Crookes'  Tube,  called  variously  in  different  countries  the 
Geisler,  Hittorf  or  Plucker  vacuum  tube.  When  making 
a  search  for  invisible  light  rays,  he  noticed  that  a  fluo- 
rescent screen  lying  nearby  shone  brightly  when  his  vac- 
uum tube  was  excited,  although  it  was  covered  with 
heavy  black  paper.  He  reasoned  that  the  black  paper 
offset  the  probability  that  the  effect  was  due  to  ultra- 
violet rays  and  that  the  phenomenon  must  be  due  to  some 
unknown  radiation  emitted  by  the  tube.  He  found  that 
if  obstacles  were  interposed  they  cast  shadows  on  the 
screen  and  in  this  way  traced  back  the  unknown  or  X- 
rays  to  their  source. 

Sir  James  Mackenzie  Davidson  has  written  down  his 
recollections  of  an  interview  with  Professor  Roentgen 
not  very  long  after  the  discovery  of  the  X-rays,  in  which 


312  MILITARY  ROENTGENOLOGY 

lie  speaks  of  the  cordial  reception  extended  him  and  of 
how  he  urged  Roentgen  to  preserve  in  a  glass  case  the 
historical  screen  (which  was  simply  a  piece  of  cardboard 
with  some  crystals  of  platinobarium  cyanid  deposited 
on  it)  and  not  keep  it  lying  about  his  laboratory. 

Terminology 

It  is  informing  to  contrast  the  good  fellowship,  as  in- 
dicated in  the  account  of  this  interview  between  two  great 
scientists — one  English,  the  other  German — with  what 
exists  today.  Feeling  has  run  so  high  even  among  sci- 
entific men  that  after  the  start  of  the  war  the  name  of 
the  official  organ  of  the  English  X-ray  specialists  was 
changed  from  the  Archives  of  the  Roentgen  Rag  to  the 
Archives  of  Radiology  and  Electrotherapeutics.  In  this 
country  the  prefix  Roentgen  is  used  because  as  yet  a  sat- 
isfactory etymological  equivalent  has  not  been  found. 
Radiology,  for  instance,  need  not  refer  to  the  science  of 
X-ray. 

Radiology,  actinology  and  similar  terms  it  is  felt  are 
not  specific.  The  American  Roentgen  Ray  Society 
adopted  the  following  terminology  until  something  bet- 
ter shall  appear : 

Roentgen  :     To  be  pronounced  rent'gen. 

Roentgen  Ray:  A  ray  discovered  and  described  by  William  Kon- 
rad  Roentgen. 

Roentgenology:  The  study  and  practice  of  the  Roentgen  Ray  as 
applied  to  medical  science. 

Roentgenologist:     One  skilled  in  Roentgenology. 

Roentgenogram  :  The  shadow  picture  produced  by  the  Roentgen 
Ray  on  a  sensitive  plate  or  film. 

Roentgenograph  (verb)  :     To  make  a  Roentgenogram. 

Roentgenoscope  :  An  apparatus  for  examination  with  the  fluo- 
rescent screen  excited  by  the  Roentgen  Ray. 

Roentgenoscopy  :     Examination  by  means  of  the  Roentgenoscope. 

Roentgenography  :     The  art  of  making  Roentgenograms. 

Roentgenize  :     To  ajiply  the  Roentgen  Ray. 


SOURCE  AND  PROPERTIES  OF  X-RAYS     313 

Roentgenization  :     Application  of  the  Roentgen  Ray. 
Roentgenism  :     Outward  effect  of  the  Roentgen  Ray. 
Roentgen  Diagnosis,  Roentgen  Therapy,  Roentgen  :     These  terms 
are  self-explanatory. 


SOURCE  AND  PROPERTIES  OF   X-RAYS 

Roentgen  traced  back  the  source  of  the  unknown  or 
X-rays  to  their  source,  which  proved  to  be  the  region  of 
impact  of  the  cathode  rays  on  the  glass  wall  of  the 
tube.  Further  investigation  revealed  the  fundamental 
fact  that  Roentgen-  or  X-rays  are  produced  whenever  and 
wherever  cathode  rays  encounter  matter. 

It  was  imagined  by  many  that  X-rays  were  present  in 
the  original  cathode  ray  beam  and  were  obtainable  by 
mere  subtraction.  But  this  was  soon  disproved  by 
the  discovery  that  when  cathode  rays  were  magnetically 
deflected  the  source  of  the  X-rays  also  moved.  The  ex- 
periment also  put  out  of  court  the  notion  that  X-rays 
were  due  to  impact  of  particles  of  metal  from  the  cathode. 

Penetration.— But  the  fascinating  feature  of  the  new 
rays  was  their  extraordinary  ability  to  penetrate  any 
substance  opaque  to  light.  The  degree  of  penetration 
was  found  to  depend  on  the  density  of  the  substance. 
For  example,  bone  is  more  absorbent  than  flesh,  and  if 
the  hand  is  placed  in  the  path  of  the  X-rays  the  bones 
stand  out  against  the  flesh  in  the  shadow  on  a  fluorescent 
screen.  It  has  been  also  ascertained  that  X-rays  affected 
a  photographic  plate  and  could  not  apparently  be  re- 
fracted or  reflected  and  unlike  cathode  rays  were  not 
bent  by  a  magnetic  or  electric  field. 

The  X-ray  differs  from  ordinary  light  in  regard  to  its 
penetrating  power.  In  the  first  place  it  is  not  influenced 
by  molecular  arrangement,  but  probably  depends  entirely 
upon  the  atomic  composition  of  the  substance.  Gener-' 
ally  the  greater  the  specific  gravity,  the  more  opaque  the 
substance  is  to  the  X-ray.    Books,  vulcanized  hard  rub- 


314  MILITARY  ROENTGENOLOGY 

ber  and  aluminum  are  very  transparent  to  the  X-ray. 
Glass  is  transparent  also  if  it  does  not  contain  too  large 
a  percentage  of  lead.  Copper,  gold,  aluminum  and  lead 
are  transparent  in  thin  plates,  although  a  quantity  of  1.5 
mm.  of  lead  is  quite  opaque. 

The  salts  of  different  metals  act  similarly  to  the  metals 
themselves  whether  in  solid  or  solution.  This  fact  is 
made  use  of  in  gastro-intestinal  and  urological  examina- 
tions, the  hollow  viscera  being  filled  with  a  solution  of 
some  metallic  salt  opaque  to  the  ray,  thus  visualizing  the 
parts  under  examination. 

Invisibility. — The  X-ray  is  invisible  yet  passes  read- 
ily through  solids  to  produce  an  image  upon  a  photo- 
graphic plate.  It  does  not  produce  the  sensations  of 
heat,  light  or  sound  and  when  it  encounters  a  solid  sub- 
stance it  gives  rise  to  secondary  X-rays;  this  is  an  im- 
portant factor  to  remember  both  for  the  protection  of 
one's  self,  when  doing  much  X-ray  work,  and  in  a  pho- 
tographic way  when  considering  the  lack  of  delineation 
of  an  image  when  raying  large  parts. 

Production.— X-rays  are  produced  whenever  a  current 
of  high  potential  is  passed  through  a  glass  bulb  exhausted 
to  a  proper  degree  of  vacuum,  having  two  wires  entering 
it  that  serve  as  the  positive  and  negative  terminals  of 
an  electric  circuit.  When  such  a  current  is  introduced  to 
such  a  tube  a  stream  of  molecules  is  repelled  from  every 
surface  of  the  cathode  or  negative  terminal  and  normally 
perpendicularly  to  this  surface.  When  this  cathode 
stream  encounters  any  solid  substance,  as  even  the  glass 
wall  of  the  tube,  it  gives  rise  to  the  form  of  motion  called 
the  X-ray. 

The  vacuum  tube  with  which  Roentgen  made  his  fa- 
mous discovery  was  pear-shaped  with  a  flat  disc  for  the 
cathode,  which  was  mounted  in  the  body  of  the  bulb  at 
its  narrow  end ;  the  anode  was  in  a  small  side  tube.  This 
pattern  of  tube  was  widely  copied,  but  it  was  found  that 
it  did  not  survive  many  of  the  prolonged  exposures  which 


SOURCE  AND  PROPERTIES  OF  X-RAYS     315 

were  necessary  to  secure  roentgenograms  of  any  value. 
Improvement  in  Tubes.— The  greatest  improvement  in 


•aT 


**^a 


^* 


D 


/ 


Fig.  12G. — Type  oe  Gas  Tube  in  Common  Use. 

the  construction  of  X-ray  tubes  since  the  original  dis- 
covery was  in  giving  the  cathode  a  concave  surface  and 
focusing  the  cathode  stream  upon  a  platinum  disc  called 


Fig.   127. — The   Victor   Hydrogen   Tube. 

the  target  or  anticathode.  This  causes  the  X-ray  to 
radiate  from  a  very  small  point  and  permits  of  much 
heavier  currents  being  used. 


31 6 


MILITARY  ROENTGENOLOGY 


This  type  is  known  as  the  gas  lube  {see  Fig.  126)  be- 
cause its  vacuum  is  controlled  by  the  release  of  oxygen 
within  it.  The  hydrogen  tube  {see  Fig.  1 27)  is  now  pre- 
ferred to  the  old  type  of  gas  tube.    In  this  hydrogen  is 


Fig.  12S. — Coolidge    Tube. 


used  to  control  the  vacuum,  because  it  is  claimed  the 
vacuum  can  be  controlled  more  readily  and  constantly. 
Coolidge  Tube. — The  greatest  advance  in  tubes  was 
made  by  Dr.  W.  L.  Coolidge,  who  in  1913  gave  to  the  pro- 
fession his  tube  {see  Fig.  128).   Its  possibilities  in  roent- 


B  A 

Fig.  128a. — Diagram  Showing  Wiring  Circuit  of  Coolidge  Tube. 

genography  and  therapy  are  tremendous.  The  chief  nov- 
elty lies  in  the  cathode,  which  consists  of  a  small  flat 
spiral  of  tungsten  wire  surrounding  which  is  a  molybde- 
num  tube,   the  two   being   electrically   connected.     The 


APPARATUS  317 

tungsten  spiral  is  heated  by  a  subsidiary  electrical  cur- 
rent and  so  becomes  a  source  of  cathode  rays.  The 
molybdenum  serves  to  focus  the  stream  of  cathode  rays 
on  the  anticathode,  which  is  of  tungsten  and  extremely 
heavy.  The  vacuum  of  the  tube  is  extremely  high,  about 
1000  times  that  of  an  ordinary  tube.  The  intensity  of 
the  X-rays  is  precisely  and  readily  controlled  by  adjust- 
ing the  temperature  of  the  cathode.  The  tube  shows 
no  fluorescence  as  does  the  ordinary  X-ray  tube. 


APPARATUS 

Suitable  current  for  driving  an  X-ray  bulb  may  be  gen- 
erated by  any  apparatus  that  will  transform  a  low  po- 
tential current  into  a  high  potential  current  that  is  uni- 
directional. 

The  so-called  influence  machine  (see  Fig.  129),  which 
consisted  of  ebonite  or  glass  plates  driven  at  high  speed 
about  a  vertical  axis,  was  merely  an  elaboration  on  a 
large  scale  of  the  old  experiment  in  physics  by  means  of 
which  electricity  is  generated  by  a  glass  wand  and  a  silk 
handkerchief.  A  current  is  produced  with  relatively 
high  voltage  and  a  very  small  amperage.  "When  working 
properly  such  a  machine  produces  a  current  unidirec- 
tional with  a  beautifully  ready  X-ray  discharge.  Such 
types  of  apparatus  have  been  abandoned  because  of 
their  unreliability  and  now  obvious  limitations. 

The  induction  coil  {see  Fig.  130)  has  been  much  used 
for  the  production  of  a  suitable  current  to  excite  an  X-ray 
tube.  Essentially  it  is  merely  a  device  for  transforming 
a  low  potential  current,  such  as  is  yielded  by  a  battery 
of  a  few  cells,  into  a  high  potential  current  of  a  kind 
suitable  for  X-ray.  It  consists  of  a  cylindrical  iron  core 
around  which  is  wound  a  coil  of  stout  insulated  wire;  this 
coil,  which  is  known  as  the  primary,  consists  of  a  rela- 
tively few  turns.     Outside  this  is  a  secondary  coil,  con- 


318 


MILITARY  K( )KNTO KNOLOGY 


sisting  of  many  thousands  of  turns  of  finer  wire  care- 
fully insulated.  Some  form  of  interrupter  is  used  in  the 
primary  circuit  and  a  condenser  offers  an  alternative 
path  to  the  break.  The  primary  circuit  is  joined  to  a 
suitable  battery  or  street  current  and  the  object  of  the 
interrupter  is  to  make  and  break  the  current  in  rapid 


Fig.  129. — The  Static  or  So-called  Influence  Machine. 


succession.  Since  in  X-ray  work  it  is  important  that  the 
current  through  the  tube  should  be  all  in  one  direction, 
the  condenser  assumed  this  function. 

The  high  tension  interrupterless  transformer  (see  Fig. 
131)  has  now  very  generally  replaced  the  induction  coil 
where  continuous  work  must  be  done,  calling  for  an  ap- 
paratus with  a  wide  range  of  flexibility.  Snook  in  1908 
first  introduced  this  type  of  apparatus.    It  is  essentially 


APPAKATUS 


319 


an  oil-immersed,  step-up  transformer  supplied  with  alter- 
nating current,  with  a  pole-changing  switch  to  rectify 
the  high  potential  alternating  current  from  the  second- 


Fig.   130. — Induction  Coil  Type  of  Apparatus  for  Producing  X-Rays 


ary  of  the  transformer,  and  a  commutator  mounted  on 
the  same  shaft  as  the  alternator  to  secure  the  perfect 
synchronism  essential  for  rectification.     Some  form  of 


320 


MILITARY  ROENTGENOLOGY 


high  tension  transformer  will  be  found  installed  by  the 
government  at  its  many  base  hospitals. 

Having  an  apparatus  capable  of  generating  the  kind  of 
current  necessary  to  excite  an  X-ray  bulb,  one  then  may 
use  the  X-ray  so  generated  either  to  register  a  desired 


Fig.  131. — Interior  View  of  Interrupterless  Transformer  Type  of 
Apparatus  Supplied  the  U.  S.  Government.  (Courtesy  Campbell 
Electric  Co.,  Lynn,  Mass.) 


part  upon  a  photographic  plate,  or  else  have  the  same 
registered  in  silhouette  upon  a  fluorescent  screen. 

At  all  times  when  using  the  X-ray  the  operator  must 
carefully  protect  himself  from  the  action  of  the  ray, 
which  is  now  well  known  to  be  destructive  of  human  tis- 
sue and  function  when  produced  in  sufficient  dosage. 


PROTECTION  FROM  RAYS  321 

PROTECTION  FROM  RAYS 

In  office  practice  and  permanent  hospitals  one  can 
be  assured  of  sufficient  protection.  The  X-ray  tube 
itself  usually  rests  in  a  suitable  lead-glass  container 
which  if  honestly  manufactured  should  cut  out  about  95 
per  cent  of  the  X-ray.  The  operator  himself  should  work 
from  behind  a  sheet-lead  or  lead-glass  protecting  device. 


Fig.  132. — Type  of  Eoentgenoscopic  Table  Supplied  the  U.  S.  Govern- 
ment, so  Constructed  that  Injured  Soldier  may  be  Examined  from 
Head  to  Feet  avithout  being  Moved.  (Courtesy  of  Campbell  Elec- 
tric Company,  Lynn,  Mass.) 

In  field  practice  such  as  one  may  encounter  in  wartime 
there  will  be  a  tendency  to  put  aside  proper  protective 
devices  to  attain  speed,  but  this  should  be  strongly 
warned  against.  In  doing  roentgenoscopy  one  should 
habitually  wear  the  lead  impregnated  apron  and  gloves 
and  lead-glass  spectacles.  While  the  X-ray  bulb  is  gen- 
erally contained  in  a  lead-protected  box  it  is  to  be  re- 
membered that  secondary  X-rays  are  given  off  from  any 
substance  impinged  upon  by  the  primary  X-ray. 

The  United  States  government  is  supplying  its  base 
hospitals  with  a  so-called  trochoscope,  a  device  some 
eight  feet  in  length  (Fig.  132),  so  that  a  patient  can  be 


322  MILITARY  ROENTGENOLOGY 

examined  rapidly  from  head  to  foot.  The  X-ray  tube, 
which  rests  in  a  properly  lead-protected  box  beneath  the 
table  top,  can  be  operated  in  any  section  of  the  table, 
thus  combining  to  aid  both  the  patient's  comfort  and 
that  of  the  operator. 


DENTAL  ROENTGENOLOGY 

Dental  Films. — The  roentgenoscopic  method  will  not 
be  generally  employed  about  the  head  and  jaw  because  of 
the  density  of  these  parts.  Usually  one  would  employ 
dental  films  or  plates  when  dealing  with  these  regions. 
The  dental  films  are  sections  of  celluloid  coated  with  a 
proper  photographic  emulsion  protected  by  a  black  paper 
covering,  outside  of  which  is  a  second  paper  covering 
red  or  orange  in  color.  The  outside  wrapper  is  waxed  to 
make  it  moisture  proof.  These  films  are  placed  within 
the  oral  cavity  itself,  in  proximity  to  the  tooth  or  teeth 
one  desires  taken.  These  films  vary  in  size,  the  one  most 
commonly  used  being  one  inch  by  one  and  one-half 
inches,  oblong  in  shape  with  rounded  corners.  An  oval- 
shaped  film  is  manufactured  especially  for  use  at  the 
angle  of  the  jaw.  Most  patients  bear  these  films  within 
the  oral  cavity  well,  but  there  are  some  who  will  gag 
and  fret  whenever  anything  but  food  is  placed  in  the 
mouth.  In  such  cases  some  form  of  dental  film  holder 
may  be  employed  successfully,  although  in  extreme  cases 
it  may  be  necessary  to  use  a  local  anesthetic  to  over- 
come the  patient's  difficulty. 

Application.— The  essential  fact  to  be  remembered  in 
using  dental  X-ray  films  or  doing  X-ray  work  at  all  is 
that  the  film  or  plate  must  be  so  placed  that  the  central 
ray  from  the  target  will  be  perpendicular  to  it.  Other- 
wise there  will  be  distortion  of  the  image,  and  perhaps 
nowhere  more  than  in  the  mouth  is  it  as  necessary  to 
observe  this  fundamental  matter  of  teclmic.    All  sorts  of 


DENTAL  ROENTGENOLOGY 


323 


curious  looking  teeth  will  result  unless  this  dictum  is 
followed  rigidly. 

McCoy,  in  the  American  Journal  of  Orthodontia,  Vol.  I, 
No.  1,  illustrates  this  desirability  (see  Fig.  133). 

Plates.— TVhere  there  is  question  of  disease  of  the  max- 
illa or  mandible  it  is  far  safer  to  use  plates  in  examining 
these  parts.  This  is  also  true  where  there  is  question  of 
disease  of  the  antrum.  In 
the  latter  case  a  plate 
taken  in  the  classical  po- 
sition (see  Fig.  134)  both 
antra  are  registered 
upon  it,  and  there  exists 
at  once  a  basis  for  genu- 
ine comparison,  since  one 
knows  that  the  densities 
registered  were  so  under 
identical  teclmic.  In  frac- 
tures of  the  jaw  it  is 
rarely  possible  to  get 
such  upon  a  dental  film, 
and  if  it  were,  the  rela- 
tions are  lost  because  of 
the  limited  size  of  the 
films. 

Position.  — Quite  as  necessary  as  a  proper  angle  is  that 
the  patient  should  be  immobile.  Whether  one  examines 
one's  cases  sitting  or  reclining  is  a  matter  of  choice. 
Some  form  of  headrest  is  at  times  desirable  to  make 
certain  immobilization  of  the  head,  although  for  most 
dental  work  using  an  apparatus  with  sufficient  output  one 
can  make  exposures  so  quickly  that  it  is  sufficient  to  ask 
the  patient  to  remain  quiet  and  not  move. 

It  is  to  be  remembered  that  in  general  a  plate  or  film 
registers  an  image  in  one  plane  only.  If  one  desires 
perspective,  then  the  so-called  stereoscopic  method  of  ex- 
amination is  adopted.    In  this  case  one  uses  a  specially 


Fig.  133. — Diagram  Showing  the  Re- 
sults of  Correct  and  Incorrect 
Techxic.  From  McCoy,  American 
Journal  Orthodontia,  Vol.   I,   No.   1. 


324 


MILITARY  ROENTGENOLOGY 


constructed  tube  stand  and  some  form  of  plate  changing 
device.  The  central  ray  being  directed  over  the  part  to 
1)0  taken,  the  tube  is  then  shifted  .*!  mm.  to  the  right  and 
left  of  center  and  an  exposure  made.  These  plates  are 
then  developed  and  viewed  either  in  a  specially  con- 
structed stereoscopic  viewing  device  as  the  Wheatstone 
(Fig.  135)  or  are  viewed  by  means  of  a  hand  stereoscope 


Fig.  134. — Showing  Normal  Antra  and  Position  Preferred  by  Author. 

and  in  this  way  perspective  is  obtained  and  a  better  idea 
of  distance  and  relationship  of  structures.  The  stereo- 
scopic method  is  also  of  value  in  the  localization  of  for- 
eign bodies  because  of  the  fact  that  one  gets  an  idea  of 
perspective. 

Triangnlation  Method.— The  United  States  govern- 
ment instructors  in  military  roentgenology  have  adopted 
the  triangnlation  method  for  localization  because  it  is 
more  accurate  using  either  a  screen  or  plate  and  also  the 


DENTAL  ROENTGENOLOGY  325 

so-called  Sutton  method.  The  triangulation  method  de- 
pends upon  three  factors,  a  known  distance  from  the  plate 
or  screen  to  the  center  of  the  tube  target,  two  exposures 
and  a  known  distance  through  which  the  tube  is  displaced, 
and  two  shadows  of  the  foreign  body  on  the  screen  or 
plate  the  distance  between  them  being  measured.  Many 
modifications  of  this  have  been  developed,  but  all  essen- 


Fig.  135. — Wheatstone  Stereoscopic  Illuminator. 

tiaily  go  back  to  the  cross-thread  method  of  localization 
described  by  Sir  James  Mackenzie  Davidson. 

Sutton  Method.—  D r.  Walter  S.  Sutton  of  Kansas  City, 
while  in  charge  of  the  American  Hospital  No.  2  at  Juilly, 
France,  in  1915,  developed  the  method  which  bears  his 
name.  It  consists  of  the  introduction  of  a  canula  directly 
into  the  flesh  after  surgical  cleanliness  is  assured,  under 
the  guidance  of  the  roentgenoscope  (see  Fig.  136).  When 
the  foreign  body  has  been  encountered  the  trochar  is 


326 


MILITARY  ROENTGENOLOGY 


withdrawn  and  a  piece  of  piano-wire  introduced,  the 
canula  withdrawn,  the  piano-wire  eat  off  to  almost  the 
skin  surface,  and  left  there  as  a  permanent  marker  until 
the  case  comes  to  operation. 


Fig.  136. — Illustrating  Method  of  Introducing  Sutton  Localizing 
Canula.  (From  American  Journal  of  Roentgenology,  Vol.  IV,  No.  7, 
by  Ed.  II.  Skinner,  Capt.,  M.O.E.C.) 

These  are  mentioned  here  as  matter  of  educational  in- 
terest. If  one  desires  to  follow  these  operations  in  detail, 
a  full  description  of  them  may  be  obtained  by  consulting 
the  bibliography. 

CYSTIC  ODONTOMATA 


Dental  Root  Cysts. — Wartime  dentistry  will  have  its 
just  share  of  all  the  familiar  lesions  of  peace  times. 
Some  form  of  the  cystic  odontomata  will  call  for  atten- 
tion daily.  The  so-called  dental  root  cyst  {see  Fig.  137) 
is  seen  more  frequently  than  any  of  the  other  types  and 
occurs  in  connection  with  the  necrotic  apices  of  devital- 


CYSTIC  ODONTOMATA 


327 


ize'd  teeth.    This  type  is  always  found  beneath  the  perios- 
teum, hence  Magitot  termed  it  a  periosteal  cyst. 

Incidence. — The  majority  of  writers  declare  the  den? 
tal  root  cyst  is  found  most  commonly  in  the  upper  jaw 
in  connection  with  the  incisors  and  bicuspid  teeth.  Scud- 
der  makes  it  a  point  of  differentiation  from  the  small 
follicular  odontoma  that  the  latter  is  situated  in  the 
lower  jaw  usually  in  connection  with  the  molar  teeth. 
Of  the  twelve  cysts  in  the  series  reported  by  New,  six 
occurred  in  the  upper  jaw  and  six  in  the  lower.    Of  those 


Fig.  137. — Simpt/e  Cysts. 


in  the  upper  jaw,  four  occurred  in  the  incisor  regions, 
one  in  the  bicuspid  and  in  one  case  the  location  was  not 
noted.  In  the  lower  jaw  three  occurred  in  the  incisor 
region,  two  in  the  bicuspid  and  one  in  the  molar  region. 
New  suggests  that  owing  to  the  coincidence  of  location 
of  this  type  of  cyst  and  supernumerary  teeth  these 
cysts  may  be  derived  from  supernumerary  anlagen. 

There  seems  to  be  no  particular  age  incidence  for  this 
type  of  cyst.  Of  the  twelve  cases  reported  by  New  the 
youngest  patient  was  12  and  the  oldest  70.  They  may 
assume  the  size  of  a  walnut,  or  indeed  be  so  small  as 
to  pass  through  the  alveolus  and  be  found  attached  to 
the  apex  upon  extraction  of  the  offending  tooth  Mar- 
shall).    {See  Fig.  138.) 

Follicular  Cysts. — The  follicular  cyst  (see  Fig.  139)  is 
not  uncommon,   says   Scudder,   though   Partsch  in   two 


328 


MILITARY  ROENTGENOLOGY 


years  saw  200  cases  of 
denial  cyst  and  only  6 
follicular  cysts.  The  term 
dentigerous  cyst  applied 
by  many  writers  to  this 
form  of  cystic  tumor  is  in- 
accurate, for  literally  der- 
moids are  tooth-bearing 
cysts.  On  the  other  hand, 
New  believes  the  designa- 
tion follicular  to  be  mis- 
leading, in  that  one  takes 
it  for  granted  without 
knowing  definitely  that 
this  type  is  developed 
from  the  follicles  of  a 
tooth. 

These  cysts,  according 
to  New,  occur  in  either  jaw 
with  about  equal  fre- 
quency and  usually  in  the 
bicuspid  and  molar  re- 
gions. They  are  seen  dur- 
ing or  shortly  after  the 
second  dentition,  except 
those  in  connection  with 
the  third  molar,  which  de- 
velops later  in  life.  They 
rarely  occur  in  connection 
w  i  t  li  deciduous  teeth. 
These  cysts  are  slow- 
growing  and  may  reach 
enormous  size.  It  is  to  be 
noted  that  in  the  follicular 
cyst,  the  cyst  wall  is  partly  a  new  growth  of  bone  and  not 
a  mere  expansion  of  a  previously  existing  capsule. 

Some  tooth,  most  commonly  a  molar  or  canine,  is  miss- 


Fig.  138. — Upper  view  shows  probe 
inserted  into  fistula  at  second  mo- 
lar. No  abscess  seen  because  taken 
at  wrong  angle.  Lower  view,  ab- 
scess of  distal  root  of  second  molar 
revealed  by  proper  technic.  Mid- 
dle view  demonstrates  extracted 
tooth  with  attached  cyst  as  record- 
ed by  Marshall.  (Courtesy  of  J.  J. 
Lowe.) 


CYSTIC  ODOXTOMATA  329 

ing  in  connection  with  the  development  of  these  cysts  and 
a  partially  developed  unerupted  one  found  in  the  cavity 
of  the  cyst.  The  crown  of  the  tooth  is  usually  complete 
and  the  root  partially  formed.     The  cyst  lies  over  the 


Fig.  139. — Follicular  or  Dentigerous  Cyst. 

crown  of  the  tooth  which  lies  at  the  base  of  the  cyst.  On 
the  other  hand  there  may  not  be  any  tooth  present  in 
the  cyst  if  the  cyst  has  begun  to  develop  at  an  early 
period  in  the  development  of  the  tooth.  Professor  Har- 
bitz  of  Christiania  has  reported  such  a  case  in  detail. 
Numerous  denticles  or  toothlike  bodies  may  be  found 
embedded  in  the  walls  of  these  cysts  or  be  found  free  in 


330 


MILITARY   ROLXTdKNOLOClY 


the  cyst  itself.  The  most  important  clinical  sign  is  the 
history  of  a  tooth  missing  in  the  region  of  the  swelling. 
Pain  usually  is  not  present  until  the  cyst  has  expanded 
to  a  fair  size  or  has  involved  the  inferior  dental  nerve. 

Multilocular    Cysts. — The   multilocular   type    of    cyst 
{see  Fig.  140)  variously  called  adamantine  epithelioma, 


Fig.  140. — Adamantinoma  or  Multilocular.  Cyst. 


epithelial  odontoma,  proliferative  follicular  cystoma,  is 
considered  locally  malignant.  It  is  made  up  of  a  collec- 
tion of  cysts  varying  in  size,  separated  by  a  thin  fibrous 
septa  and  in  some  cases  by  osseous  tissue.  It  usually 
involves  the  mandible.  It  is  an  insidious  growth  usually 
involving  the  angle  of  the  jaw. 


ROENTGENOLOGY  IN  ARMY  CASES        331 

The  exciting  cause  of  these  growths  Marshall  believes 
to  be  some  form  of  trauma.  The  injury  may  be  in  the 
form  of  irritation  from  an  erupting  tooth.  The  lower 
third  molar  is  notoriously  difficult  to  erupt  and  is  more 
frequently  impacted  than  any  tooth  in  the  mouth.  "It  is 
interesting  to  note,  "says  New,  "that  it  is  in  this  region, 
and  at  the  average  age  of  33  years,  during  or  just  at  the 
time  of  eruption  of  the  lower  third  molar,  that  these 
cysts  occur,  but  it  is  difficult  to  obtain  conclusive  evi- 
dence of  the  association  of  the  eruption  and  impaction 
of  teeth  to  adamantinomata." 

While  a  diagnosis  of  these  tumors  can  be  made  clini- 
cally it  is  far  more  scientific  to  submit  prospective  cases 
to  Roentgen  examination.  The  roentgenogram  in  the 
simple  variety  of  dental  cyst  will  show  a  unilocular  cyst 
in  connection  with  a  devitalized  tooth.  In  the  follicular 
cyst  the  X-ray  will  demonstrate  the  presence  oJ  an  un- 
developed tooth  within  the  cyst  wall  and  in  the  adamanti- 
nomata multiple  cysts  and  their  dividing  septa  will  be 
made  out.  The  differentiation  between  a  giant  cell  sar- 
coma and  adamantinoma  may  be  difficult  and  may  have  to 
be  made  at  the  time  of  operation  microscopically. 


ROENTGENOLOGY  IN  ARMY  CASES 

It  will  now  be  quite  as  convenient  in  army  practice  as 
at  home  to  employ  Roentgen  examination  before  and 
during  orthodontic  procedures.  Proper  Roentgen  ex- 
amination will  reveal  unerupted  and  impacted  teeth,  giv- 
ing the  story  of  impaction  and  why  and  laying  the  foun- 
dation for  j^roper  surgical  interference  when  indicated 
(see  Fig.  141). 

Roentgen  examination  will  reveal  improperly  filled 
root  canals,  perforations,  foreign  bodies  such  as  dental 
broaches  in  the  root  canals,  unextracted  roots  and  other 


332 


MILITARY  ROENTGENOLOGY 


pathological  conditions  that  may  account  for  septic  proc- 
esses and  disease  in  the  jaws. 

Fractures.— Fractures  of  the  upper  and  lower  jaws  will 
fall  to  the  lot  of  the  army  dentist,  however,  far  more 
frequently  than  would  be  the  case  in  civil  practice0     It 


Fig.  141. — Impacted  Lower  Third  Molar. 


will  be  necessary  to  know  the  position  of  the  fragments 
for  the  correct  fashioning  of  the  dental  splints,  and  here 
again  one  will  find  Roentgen  examination  often  essential. 
Or  the  Upper  Jaw. — Fractures  of  the  upper  jaw  {see 
Fig.  142)  always  occur  from  direct  violence.  The  direc- 
tion of  the  line  of  fracture  is  very  varied  according  to 
the  direction  and  character  of  the  force.    A  blow  upon 


ROENTGENOLOGY  IN  ARMY  CASES       333 

the  cheek  may  crush  the  malar  bone  into  the  antrum.  By 
a  blow  on  the  upper  lip  a  fracture  of  the  alveolar  border 
can  be  produced.  Severe  degrees  of  violence  may  sepa- 
rate the  superior  maxillary  bones  one  from  the  other. 
Gunshot  fractures  may  produce  any  possible  degree  of 
destruction  of  the  bone.  The  diagnosis  of  fracture  in 
such  cases  is  entirely  easy,  Roentgen  examination  being 


Fig.  142. — Fracture  of  Ramus  op  Mandible  and  Superior  Maxilla. 


made  to  give  one  the  degree  of  fracture  and  relation- 
ship. 

Of  the  Lower  Jaw. — The  lower  jaw  (see  Fig.  143)  is 
broken  more  often  than  any  other  bone  of  the  face.  A 
frequent  cause  is  a  blow  upon  the  chin,  less  often  a  blow 
from  the  side.  The  fracture  is  rarely  comminuted  except 
in  case  of  gunshot  wounds.  The  coronoid  process  is 
rarely  broken,  the  condyloid  process  more  frequently, 
and  its  fracture  is  often  associated  with  fractures  of 
other  bones.  Fracture  of  the  alveolar  border  is  common, 
as  are  also  fractures  through  the  body  of  the  jaw.    Frac- 


334 


MILITARY   ROENTGENOLOGY 


hires  of  the  body  behind  the  teeth  arc  rare.  In  the  frac- 
tures in  the  horizontal  portions  of  the  body  the  line  of 
fracture  is  usually  vertical.  Fractures  through  the 
angle  or  ascending  ramus  are  oblique  and  transverse. 
Owing  to  the  proximity  of  the  mucous  membrane  of  the 
mouth  many  fractures  of  the  lower  jaw  are  compound. 


Fig.  143. — Fracture  of  Lower  Jaw  from  Gunshot. 


It  is  to  be  remembered  that  roentgenograms  of  the 
lower  jaw  made  in  a  lateral  or  oblique  position  may 
fail  to  demonstrate  a  fracture  at  or  near  the  symphysis. 
In  a  case  of  suspected  fracture  at  this  point  the  patient's 
chin  should  be  placed  upon  the  plate  and  the  ray  passed 
from  above  downward  (Fig.  144). 


ROENTGENOLOGY  IN  ARMY  CASES       335 

Dislocation.— Dislocation  of  the  lower  jaw  can  be  diag- 
nosed clinically  with  ease  from  its  clinical  signs,  the  jaw 
projecting  forward  and  incapable  of  movement.  The 
condyle  can  be  felt  anterior  to  its  normal  place  and  a 
corresponding  depression  can  be  felt  at  the  site  of  the 
glenoid  cavity. 


Fig.  144. — Fracture  of  Lower  Jaw  near  Symphysis  not  Easily  Demon- 
strated in  Lateral  View. 

Gunshot  Wounds.— Gunshot  wounds  of  the  jaws  (Figs. 
145,  146)  mean  frequently  great  loss  of  bone  substance 
either  by  direct  injury  or  necrosis,  so  that  the  oral  sur- 
geon has  had  a  tremendous  field  of  endeavor  opened  up 
during  this  war  in  all  kinds  of  plastic  and  orthopedic  pro- 
cedures (Fig.  147).  Here,  too,  Roentgen  examination  will 
be  of  value  in  checking  up  the  post-operative  and  end  re- 
sults of  bone  transplants  and  the  like. 


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ROENTGENOLOGY  IN  ARMY  CASES        337 

This  is  not  by  any  means  the  story  of  dental  roent- 
genology but  is  meant  to  be  suggestive  of  its  possibilities 


Pig.  147. — Treatment  of  Gunshot  Wounds.  Same  cases  as  seen  in  Figs. 
145,  146,  seven  weeks  after  treatment  by  American  dental  surgeons 
behind  the  firing  line. 

as   far  as  the  limitations   of  the  present  work  would 
permit. 


CHAPTER  XIII 

VENEREAL  DISEASES    (SYPHILIS)    AND  DISEASES  OF 
MOUTH    AND    NOSE 

William  Chenery,  M.D. 

The  efficiency  of  the  soldier  depends  largely  on  his 
health.  He  must  be  ablebodied  to  start  with;  in  fact, 
the  flower  of  the  land  is  picked.  These  men,  untrained 
and  used  to  entirely  different  surroundings,  food,  cloth- 
ing and  habits,  are  the  material  of  which  soldiers  are 
made.  The  country  must  do  its  utmost  towards  promot- 
ing and  preserving  their  health.  Sickness  means  handi- 
cap. The  cause  and  prevention  of  disease  must  be  found 
out  as  far  as  possible.  Prevention  is  far  better  than 
cure. 

Metabolic  and  Infective  Disease.— There  are  two 
classes  of  diseases :  first,  those  arising  within  the  body, 
due  to  disturbances  of  nutrition,  assimilation  and  elimi- 
nation. There  is  a  lack  of  harmony  in  waste  and  repair. 
This  is  seen  in  gout,  diabetes,  nervous  conditions,  arte- 
riosclerosis and  rheumatism;  second,  those  diseases  due 
to  causes  without  the  body  and  depending  on  invasion 
and  multiplication  of  special  germs  or  bacteria  in  the 
body.  These  are  called  infective  diseases.  For  the  pro- 
duction of  infective  diseases  two  factors  are  necessary: 
the  germs  must  get  into  the  body  in  sufficient  numbers; 
they  must  find  a  suitable  soil  and  propagate.  The  en- 
trance of  the  bacteria  is  through  the  respiratory  or  di- 
gestive tracts  or  inoculation  through  the  skin.  A  lowered 
vitality  means  a  chance  for  invasion  of  bacteria. 

338 


INFECTIVE  DISEASES  339 


INFECTIVE  DISEASES 


Diseases  Prevalent  in  the  Army.— Relaxed  discipline, 
ill-ventilated  camps,  neglect  of  hygienic  rules,  also  lack 
of  care  of  teeth,  result  in  the  dissemination  of  infective 
germs  producing  disease  and  death.  The  most  prevalent 
diseases  in  the  army  in  their  order  are — venereal  dis- 
eases, tonsillitis,  suppurative  skin  diseases,  acute  and 
chronic  bronchitis,  enteritis,  influenza,  alcoholism,  ma- 
laria, rheumatism,  measles,  mumps,  tuberculosis.  Ton- 
sillitis is  second  and  bronchitis  a  close  follower.  Bar- 
racks overcrowded,  overheated  and  with  poor  ventila- 
tion, mean  air  infection,  then,  tonsillitis  and  diseases  of 
the  respiratory  tract  easily  develop. 

The  order  of  deaths  for  the  entire  population  in  1910 
was  tuberculosis,  heart  disease,  diarrhea,  enteritis,  pneu- 
monia, nephritis.  In  war  times  morbidity  and  mortality 
necessarily  increase.  The  highest  rate  of  sickness  and 
death  is  in  the  younger  soldiers  under  twenty  years,  in 
the  first  year  of  service,  and  in  those  over  forty  years 
of  age. 

From  these  remarks  just  made  it  would  appear  that 
the  most  important  diseases  that  impair  the  health  of 
the  soldiers  are  the  infective  group.  Since  there  are  at 
all  times  in  the  nose,  throat  and  mouth  a  large  variety 
of  bacteria,  whose  activity  depends  on  a  lowered  vitality, 
it  is  necessary  to  look  carefully  after  the  hygiene  of  the 
nose,  the  nasopharynx  and  the  mouth. 

Inasmuch  as  venereal  diseases  head  the  list  of  illnesses 
of  soldiers,  syphilis  or  lues  will  be  first  spoken  of  be- 
cause of  its  increasing  importance. 

Syphilis 

Alcoholic  intemperance  and  sexual  debauchery  are  al- 
ways closely  associated.    The  abolition  of  the  canteen,  at 


340  VENEREAL  DISEASES 

least  in  times  of  war,  is  a  very  necessary  precaution  to 
keep  up  the  high  efficiency  of  the  soldier.  During  ac- 
tive war  times  venereal  diseases  are  said  to  be  less  prev- 
alent because  the  soldier  is  more  occupied  and  has  less 
leisure  and  less  temptation  for  immorality.  While  pre- 
ventives have  a  certain  amount  of  value,  they  are  by  no 
means  sure.  The  education  of  the  soldier  is  necessary. 
Be  must  be  taught  proper  appreciation  of  the  preva- 
lence and  gravity  of  venereal  diseases. 

Results  of  Syphilis.— According  to  Lesser,  a  third  of  all 
syphilitics  eventually  die  of  tuberculosis,  paralysis,  or 
aortic  aneurism.  The  predilection  of  tertiary  syphilis 
for  the  nervous  system  is  also  well  known.  All  deaths 
from  general  paralysis,  locomotor  ataxia,  as  well  as  one- 
half  of  those  from  paraplegia  and  softening  of  the  brain, 
are  attributed  to  syphilis.  It  is  supposed  by  some  that 
the  cure  of  syphilis  by  salvarsan  is  sure  and  quick  and 
that  indiscretion  can  be  easily  corrected.  Such  is  not 
the  case.  It  should  be  also  remembered  that  syphilis 
uncured  may  be  transmitted  to  the  newborn. 

Prevention.— How  to  control  the  social  evil  has  been  a 
subject  of  much  discussion  and  various  attempts  have 
been  made  with  varying  success.  The  moral  standard 
should  be  upheld.  Camp  life  should  be  made  as  pleas- 
ant as  possible  and  Bishop  Lawrence's  idea  of  furnish- 
ing each  camp  with  a  picture  machine  with  the  latest 
reels  is  certainly  one  way  of  entertaining  and  lessening 
the  temptations  of  the  soldiers  off  duty.  Games  of  all 
sorts,  reading  rooms  and  Y.  M.  C.  A.  quarters  should  be 
established  to  take  up  the  time  and  attention  during  off 
hours. 

Diagnosis  and  Early  Treatment.— The  discovery  of  the 
cause  of  syphilis  and  the  Wassermann  reaction  have  ren- 
dered an  carry  diagnosis  of  the  disease  possible,  and 
treatment  and  cure  much  more  certain.  Early  and  per- 
sistent treatment  means  much  less  damage  to  the  gen- 
eral system.     The  Wassermann  reaction  also  helps  to 


INFECTIVE  DISEASES  341 

recognize  latent  syphilis  when  manifest  symptoms  are 
absent,  and  also  materially  aids  in  determining-  when  the 
patient  is  cured.  A  positive  Wassermann  is  of  great 
value.  On  the  appearance  of  the  primary  sore  a  positive 
diagnosis  can  be  made  by  finding  the  specific  germ  in  the 
exudate,  and  in  nearly  all  cases  a  positive  Wassermann 
can  be  obtained  by  the  fourth  week.  The  chief  trouble 
with  the  Wassermann  test  is  laying  too  much  stress  on  a 
single  negative  result.  The  early  detection  of  syphilis 
and  isolation  of  the  patient,  during  the  active  symptoms, 
is  important  because  of  the  possible  danger  to  others  in 
camp.     The  syphilitic  is  a  menace  in  any  community. 

Location  of  Primary  Sore.— It  should  be  remembered 
that  syphilis  is  not  purely  a  venereal  disease,  and  that 
it  may  be  transferred  from  one  to  another  innocently. 
While  the  primary  lesion  is  found  most  frequently  on 
the  genitalia,  it  is  often  found  in  the  mouth.  The  sources 
of  extragenital  syphilis  have  received  much  attention 
from  Dr.  Buckley  and  his  findings  emphasize  the  fre- 
quency of  nonvenereal  infection.  It  carries  its  own  warn- 
ing and  the  great  need  of  care,  especially  to  dentists, 
who  are  constantly  examining  the  mouth.  The  sources, 
according  to  Buckley,  are :  lip  1819  cases ;  breast 
(from  suckling  infants)  1148  cases;  buccal  cavity  734 
cases;  fingers  467  cases;  tonsils  308  cases;  throat  267 
cases ;  tongue  157  cases ;  chin  146  cases ;  cheek  145  cases ; 
gums  42  cases;  arms  2  cases;  hand  1  case;  nostril 
1  case;  hard  palate  1  case;  eyelid  1  case.  In  all  he  re- 
ports 9071  cases  of  extragenital  syphilis  and  fifty  per 
cent  of  these  were  produced  by  some  form  of  oral  syphilis. 

Course  of  Disease.  —  Syphilis  does  not  always  follow  a 
typical  course.  It  may  omit  certain  stages.  One  may 
not  see  the  early  manifestations,  or,  if  seen,  they  are  of 
such  a  mild  form  as  not  to  be  recognized,  only  to  break 
out  violently  in  a  tertiary  form  at  a  later  day.  The 
disease  may  be  acquired  or  congenital.  The  vast  major- 
ity of  infections  are  acquired  after  birth.     It  is  a  con- 


342  VENEREAL  DISEASES 

stitutional  disease,  contagious  in  character,  chronic  in 
course  and  affects  all  parts  of  the  body.  It  may  be 
transmitted  by  heredity  or  inoculation  on  any  portion  of 
the  body  by  the  syphilitic  virus.  To  acquire  the  disease 
two  factors  are  necessary:  first,  the  virus  containing  the 
Spirochaeta  pallida  (Trepone  a  pallidum),  and  second, 
the  abraded  surface  of  skin  or  mucous  membrane  through 
which  the  microorganisms  may  enter  the  system. 

Treponema    Pallidum.— The   Spirocheta   pallida   is    a 
spiral  organism  having  six  to  eight  coils  or  rings;  it  may 


Fig.  148. — Spirochaeta  Pallida  (two  in  center)  and  Refrixgens  (three, 
more  deeply  stained).      (Hoffmann). 

have  as  many  as  twenty-four,  regular  and  close  together. 
It  moves  along  its  own  axis  by  rotation,  whereas  the 
Spirochaeta  refringens,  which  is  often  found  in  the 
mouth,  moves  by  flagellation  or  snakelike  motion. 

Sources.  — Of  the  extragenital  cases  of  syphilis  seventy- 
five  per  cent  begin  around  the  head.  The  infected  pipe, 
drinking  cups,  musical  instruments,  kissing,  infected 
household  implements  are  the  common  sources  of  this 
disease. 

Stages  of  Syphilis 

For  the  sake  of  convenience  syphilis  is  divided  into 
three  periods :  the  primary,  the  secondary  and  the  ter- 
tiary   manifestations.      Contact    of   the    virus    with    an 


INFECTIVE  DISEASES  343 

abraded  surface  in  any  portion  of  the  body  having  oc- 
curred, absorption  takes  place  through  the  blood  vessels 
and  lymphatic  circulation.     This  is  inoculation. 

Primary  Stage.  — There  is  a  period  of  primary  incuba- 
tion following  infection,  which  lasts  about  three  weeks 
and  then  appears  what  is  called  the  primary  lesion  or 
chancre.  This  occurs  at  the  point  of  inoculation.  A  true 
chancre  is  hard  or  indurated  at  its  base  and  is  quite 
different  from  a  soft  chancre  or  chancroid  whose  infec- 
tion is  local  and  limited  to  enlargement  or  suppuration 
of  the  nearest  glands.  A  hard  chancre,  at  first,  is  an 
elevated  spot  which  slowly  enlarges  and  becomes  firm,  in- 
durated or  button-like  in  feeling  in  contrast  to  the  sur- 
rounding tissue.  The  softer  the  tissue  in  which  it  is  sit- 
uated, the  more  marked  is  the  induration.  In  certain  sit- 
uations, as  for  example  the  finger,  the  induration  may  be 
slight,  and  so,  scarcely  noticed  until  later  symptoms  make 
known  the  diagnosis.  This  primary  sore  increases  in 
dimension,  has  an  ulcerated  surface  and  shows  no  ten- 
dency to  heal.  It  rarely  is  larger  than  a  ten-cent  piece. 
It  is  usually  single  but  may  be  double  providing  inocu- 
lation has  taken  place  at  the  same  time. 

Secondary  Stage.— Following  this  is  a  second  period 
of  incubation,  during  which  the  glands  nearest  the  point 
of  invasion  or  chancre  become  enlarged;  then  follows  a 
general  glandular  enlargement.  This  second  period  of 
incubation  lasts  about  six  weeks,  then  occur  what  are 
called  the  secondary  symptoms,  which  last  from  one  to 
three  years  and  have  a  predilection  for  mucous  mem- 
branes and  skin.  After  the  formation  of  the  primary 
sore  and  during  the  period  of  incubation  to  the  develop- 
ment of  the  constitutional  manifestations,  evidences  of 
lymphatic  absorption  of  the  disease  can  be  found  in  the 
glands  nearest  to  the  primary  sore;  if  the  genitals,  those 
of  the  groin  are  first  affected ;  if  the  fingers,  the  epitroch- 
lear ;  if  the  lips,  the  submaxillary.  From  about  the  tenth 
to  the  fourteenth  day  these  enlargements  are  quite  no- 


344 


VENEREAL  DISEASES 


ticeable   and   are   hard,  non-painful  kernels   under  the 
skin. 

Secondaky  Symptoms. — The  secondary  stage  is  ush- 
ered in  with  feverishness,  slight  sore  throat,  pains  in 
the  limbs,  headache  and  a  feeling  of  malaise,  and  soon 
after  there  appears  on  the  body  an  eruption  of  rose  col- 
ored blotches  or  spots  not  unlike  the  appearance  of 
measles.  This  may  cover  a  part  or  the  whole  of  the  body. 
It  is  often  transitory  in  its  appearance;  it  lasts  about 


Fig.  149. — Chancre  of  the  Upper  Lip   (Porter). 

three  weeks  and  disappears  with  a  very  slight  scaling  of 
the  skin.  The  sore  throat  may  subside;  the  headache 
may  diminish;  the  initial  sore  may  even  heal,  thus  giv- 
ing a  feeling  of  false  security  to  the  patient.  After  a 
short  time  usually  a  papular  eruption  appears  on  the 
body  and  the  scalp  becomes  involved;  the  hair,  the  eye- 
brows and  lashes  fall  in  patches,  giving  a  moth-eaten 
appearance.  Then  occur  the  lesions  of  the  mouth  which 
are  the  most  important  of  the  whole  body. 

Lesions  of  the  Mouth. — These  lesions  are  among  the 
early  symptoms  and  are  the  most  destructive  and  re- 


INFECTIVE  DISEASES  345 

bellious  to  treatment  and  the  most  apt  to  recur.  They 
are  also  very  contagious,  and  there  is  no  doubt  but  that 
more  cases  of  extragenital  syphilis  are  acquired  from 
these  mouth  lesions  than  all  the  local  lesions  elsewhere 
in  the  body.  It  must  be  remembered  that  the  secretions 
from  the  mucous  patches  of  the  mouth  as  well  as  the 
blood  and  lymph  during  the  second  stage  of  the  disease 
are  highly  contagious. 

Syphilis  of  the  Month 

As  seen  in  the  mouth  and  throat  there  are  five 
forms  in  which  syphilis  may  occur.  First  there  may  be 
a  primary  lesion;  usually  this  is  seen  on  the  lips,  the 
tongue,  the  fauces,  the  tonsils.  Then  the  second  form 
or  erythema,  a  congestion  that  occurs  at  the  beginning 
of  the  secondary  rash  and  con- 
sists of  a  diffuse  redness  of  the 
posterior  parts  of  the  mouth,  con- 
fined chiefly  to  the  soft  palate  and 
uvula.  After  a  time  there  occurs 
the  so-called  butterfly  manifesta- 
tion, which  is  quite  characteristic. 
This  area  of  redness  is  sharply 
defined  from  normal  mucous 
membrane  at  the  juncture  of  the 
hard  and  soft  palate.  This  soon 
disappears  and  next  is  developed  FlG-  p1tchesUC°US 

the    third    and    most    important 
form  of  oral  syphilis,  the  mucous  patch. 

Mucous  Patches.— In  number  these  patches  may  be  one 
or  multiple.  They  are  grayish  ^vliite  spots  varying  in 
size  and  shape,  but  more  or  less  round,  and  not  unlike 
the  ordinary  canker  spot  so  often  seen.  They  are  not 
elevated  but  have  a  reddish  hyperemic  zone  around 
them.  They  are  situated  usually  on  the  inside  of  the 
lip  and  cheek,  tongue  and  gums,  the   soft   palate   and 


346  VENEREAL  DISEASES 

tonsils.  When  occurring  at  the  angle  of  the  mouth  they 
are  troublesome  and  hard  to  heal.  These  patches  appear 
eight  to  twelve  weeks  after  the  primary  sore  and  tend 
to  recur  again  and  again.  The  simple  canker  sore  is 
more  painful,  develops  quickly  and  gets  well  in  a  few 
days.  Mucous  patches  look  not  unlike  the  mucous  mem- 
brane when  touched  with  a  strong  solution  of  nitrate  of 
silver,  with  the  addition  of  a  red  zone  around  the  whitish 
opalescent  patch.  These  mucous  patches  are  extremely 
contagious  and  infect  saliva  which  often  conveys  the  dis- 
ease. Contact  with  a  sharp  or  ragged  tooth  prolongs 
or  causes  a  local  outbreak. 

Infection  from  Saliva.— Here  might  be  quoted  an  in- 
teresting example  of  the  contagiousness  of  saliva.  Two 
teamsters,  one  of  whom  had  the  habit  of  chewing  the  lash 
of  his  whip,  one  day  were  driving  in  opposite  directions. 
The  one  who  chewed  the  lash  playfully  snapped  his  whip 
in  the  direction  of  his  friend,  hitting  him  on  the  tip  of 
the  nose  and  causing  an  abrasion  of  the  skin.  The  saliva 
carried  the  spirocheta  and  a  primary  sore  developed  in 
due  time. 

Another  interesting  case  is  that  of  a  young  man  who, 
like  many  others,  used  to  smoke  cigarettes.  (After  puffing 
a  little  one  allowTs  the  cigarette  to  rest  listlessly  on  the 
lower  lip;  the  rice  paper  adheres  to  the  mucous  mem- 
brane and  on  removing  the  cigarette  quickly,  a  slight 
abrasion  of  the  mucous  membrane  results.)  In  the  case 
spoken  of  (one  in  actual  practice)  a  young  man  met  a 
young  lady  who  liked  to  smoke  cigarettes.  She  did  not 
happen  to  have  one  and  wras  not  averse  to  a  second-hand 
smoke.  She  snatched  the  one  from  the  mouth  of  the 
young  man,  took  a  fewT  whiffs,  then  passed  it  back.  In 
three  weeks  he  developed  a  primary  sore  on  his  lower 
lip  caused  by  inoculation  through  an  abrasion.  There- 
fore if  a  man  has  a  pipe,  he  should  keep  it  in  his  pocket. 
It  doesn't  pay  to  let  his  neighbor  have  it. 


INFECTIVE  DISEASES 


347 


Fig.  151. — Gumma  of,  Tongue. 


In  mouth  infection  there  must  be  an  abraded  surface 
to  come  in  contact  with  the  active  virus.  The  spirochete 
lives  in  the  open  air  perhaps  five  minutes  and  if  well 
taken  care  of  may  be  active  for  an  hour  or  two,  but  the 
drying  process  of  the  air  seems  to  make  it  inert  and  pro- 
tects people  from  having 
syphilis.  Moisture  and  heat 
tend  to  prolong  its  activity. 
The  period  of  primary  in- 
cubation is  about  three 
weeks.  The  secondary  pe- 
riod lasts  from  one  to 
three  years,  which  is  fol- 
lowed by  a  period  of  two  to 
four  years  of  quiescence, 
after  which  the  tertiary  period,  which  lasts  indefinitely, 
commences. 

Tertiary  Stage.— The  tertiary  period  is  characterized 
by  gummata,  deep  ulceration  and  destruction  of  bone 
and  tissue.    Irregular  nodules  or  gummata  form  in  any 

portion  of  the  body. 
They  may  be  very  small 
like  millet  seed  or  large 
like  marbles.  They  are 
hard  and  firm  at  first 
and  later  become  soft. 
Necrosis  is  followed  by 
absorption  and  break- 
ing down  of  tissue  asso- 
ciated with  more  or  less 
pain.  Then  follows  a 
deep  punched  ulcer  or  a  necrosis  of  bone  with  sequestra 
formation  accompanied  with  more  or  less  odor.  Tissues 
and  bone  are  alike  affected.  If  these  ulcers  heal  under 
treatment  they  leave  a  stellate  scar,  which  is  quite  char- 
acteristic. 

Briefly,  then,  there  are:  (a)  a  period  of  primary  incu- 


Fig.   152. — Gumma  of  Tongue. 


348  VENEREAL  DISEASES 

bation  following  inoculation,  lasting  about  three  weeks; 
(b)  a  period  of  primary  symptoms,  chancre  and  begin- 
ning1 adenopathy;  (c)  a  period  of  secondary  incubation, 
lasting  about  six  weeks;  (d)  a  period  of  secondary  symp- 
toms, lasting  from  one  to  three  years;  (e)  an  interme- 
diate period,  of  two  to  four  years ;  and  (/)  a  tertiary  pe- 
riod, lasting  indefinitely. 

Parasyphilitic  Symptoms.— These  manifestations  are 
tabes,  dementia,  paralysis,  arteriosclerosis,  aneurism, 
aortitis,  amyloid  degeneration. 

Hereditary  Syphilis.— In  hereditary  cases  there  is  no 
primary  lesion.  There  are  only  the  secondary  and  ter- 
tiary manifestations.  One  class  of  symptoms  may  not  be 
seen  or  they  may  be  so  slight  as  not  to  be  noticed,  only  to 
show  up  later  in  the  tertiary  form  of  the  disease.  In- 
stead of  waiting  two  to  four  years  for  the  tertiary  symp- 
toms, they  may  appear  in  perhaps  six  or  nine  months  or 
the  secondary  symptoms  may  be  delayed  and  not  show 
up  until  later  than  usual.  The  course  of  the  disease  is 
by  no  means  regular;  often  symptoms  recur  when  the 
disease  is  thought  to  be  cured. 


SYPHILIS  OF  THE  MOUTH  ILLUSTRATED 

These  points  are  especially  important-  to  dentists.  The 
primary  sore  may  appear  anywhere  on  the  body.  In  or- 
der to  have  inoculation  there  must  be  an  abrasion  and 
then  the  active  spirochete  must  be  rubbed  in  just  like  or- 
dinary vaccination. 

Dark  Field.— The  pallida  seen  in  the  dark  stage  micro- 
scope is  just  like  a  piece  of  fine  spiral  wire  with  perfect 
coils.  There  may  be  six,  eight  or  any  number  of  coils 
up  to  twenty-four.  They  differ  decidedly  from  the  Spiro- 
cheta  refringens  which  is  constantly  in  the  mouth.  The 
latter  is  thickened  in  its  center  and  has  tapering  ends 


SYPHILIS  OF  THE  MOUTH  349 

and  moves  by  flagellating  or  whipping  from  side  to  side 
in  a  wriggling  motion.  The  pallida  always  moves  with 
a  spiral  motion.  The  spirals  are  perfect  in  the  picture 
and  differ  from  the  refringens  variety.  The  Spirocheta 
pallida  can  be  found  in  the  serum  from  a  primary  sore 
very  early  and  an  absolute  diagnosis  result.  The  figure 
shows  the  primary  sore  beginning  as  a  pimple,  gradually 
enlarging  to  the  size  of  a  ten-cent  piece.    It  appears  any- 


Fig.  153. — Late  Secondary  Lesion. 

where  on  the  body  where  inoculation  has  taken  place — 
the  genitals,  mouth  or  finger,  etc.  The  suriace  is  slightly 
ulcerated  with  only  very  little  secretion.  The  edges  are 
slightly  raised  and  if  it  is  felt  between  the  thumb  and 
forefinger  it  has  an  indurated  or  button-like  feeling. 
Sometimes  it  is  only  parchment-like  in  feeling  but  usually 
hard,  and  especially  in  soft  tissue  has  a  decided  thick  in- 
durated base.  This  sore  has  no  tendency  to  heal  and 
does  not  get  larger  than  a  ten-cent  piece.  This  is  fol- 
lowed by  enlargement  first  of  the  glands  nearest  to  the 
sore;  in  this  case  the  submaxillary  glands  are  first  en- 


;:;>(> 


VENEREAL  DISEASES 


larged.     One  may  have  a  double  chancre  but  both  in- 
oculations must  take  place  at  the  same  time. 

Figure  154  shows  a  very  early  stage  of  the  secondary 
lesion  of  syphilis  with  skin  eruption.     The  whitish  mu- 


Fig.  154. — A  Very  Early  Stage  of  the  Secondary  Lesion  of  Syphilis, 
with  Skin  Eruption.     (Photograph  by  Dr.  C.  M.  Whitney.) 

cous  patch  on  the  edge  of  the  tongue,  more  or  less 
rounded,  with  a  red  zone  around  it  will  be  noted.  When 
the  disease  is  active  this  tends  to  enlarge  with  serpiginous 
edges.    This  is  quite  characteristic. 

When  examining  the  mouth,  if  there  is  a  suspicious  sore 
around  the  lips,  the  dentist  must  not  handle  it  himself. 


SYPHILIS  OF  THE  MOUTH  351 

The  patient  must  do  it.  He  should  roll  down  the  lower 
lip  so  that  the  mucous  membrane  can  be  seen;  then  roll 
up  the  upper  lip  and  protrude  the  tongue  in  the  me- 
dian line,  moving;  it  to  the  right  and  to  the  left.  In  this 
way  one  may  get  a  very  fair  view  of  the  mucous  mem- 
brane of  the  lips  and  tongue  and  the  anterior  portion 
of  the  mouth.  Opalescent  patches  in  the  mouth  asso- 
ciated with  a  rash  on  the  body  and  a  general  enlarge- 
ment of  the  cervical  glands,  and  falling  hair  or  eyebrows 
should  arouse  suspicion  and  lead  one  to  seek  expert  ad- 
vice. A  persistent  ulcer  or  sore  at  the  angle  of  the  mouth 
is  always  suspicious. 

Salvarsan  does  not  eliminate  syphilis;  it  is  only  an- 
other weapon  with  which  to  fight  the  disease.  Early 
diagnosis  by  microscope  or  by  the  Wassermann  serologic 
cal  test  helps  to  fight  the  disease  earlier  and  with  better 
results.  Mercury  and  iodid  still  have  an  important 
place  in  the  treatment  of  this  disease.  Alcoholism  and 
neglect  of  cleanliness  of  the  mouth  tend  to  make  mouth 
lesions  more  common.  The  use  of  tobacco  also  prolongs 
the  disease. 

Care  of  Mouth. — In  the  earlier  treatment  of  lues  the 
patient  was  frequently  salivated  from  the  mercurial  rubs. 
The  teeth  became  loosened ;  the  gums  tender,  swollen  and 
bleeding;  the  patient  unable  to  bite,  with  saliva  drooling 
and  breath  offensive.  This  condition  is  seldom  seen  with 
modern  treatment.  Sharp  or  ragged  teeth  are  very  apt 
to  cause  excoriations  and  keep  up  mucous  patches.  Well 
cared  for  teeth  and  mouth  hygiene  are  very  necessary 
during  the  treatment  of  syphilis. 

Frequently  there  is  an  ulceration  of  the  tonsil,  destruc- 
tive and  simulating  syphilis.  It  is  not  syphilis  but  Vin- 
cent's angina,  a  destructive  process  with  a  predilection 
for  the  tonsil.  The  microscope  easily  reveals  its  true 
character.  It  is  caused  by  the  Bacillus  fusiformis  and 
the  Spirocheta  refringens.     This  is  very  common  in  the 


352  VENEREAL  DISEASES 

Army.  It  must  be  remembered  that  the  patient  may  have 
syphilis  as  well  as  tuberculosis  at  the  same  time. 

History  is  very  important  in  tracing  out  old  ulcers, 
gummata  and  sears.  A  gumma  (see  Figures  151,  152) 
may  appear  anywhere  in  the  body  and  may  be  small  or 
large.  It  gradually  breaks  down  with  destruction  of  tis- 
sue and  is  followed  by  a  stellate  cicatrix.  Frequently  the 
roof  of  the  mouth  is  affected  so  that  the  hard  palate  is 
destroyed  and  speech  interfered  with. 

The  primary  sore  occurs  exactly  at  the  point  of  inocu- 
lation wherever  that  may  be.  Mucous  membranes  and 
skin  are  where  the  secondary  forms  of  the  disease  are 
manifested.  The  upper  and  lower  lips,  the  angles 
of  the  mouth,  the  sides  of  the  tongue  and  the  fauces 
must  be  examined.  Gummata  may  appear  anywhere  but 
are  frequently  found  involving  the  roof  of  the  mouth, 
the  nasal  septum,  the  tongue,  the  frontal  bone  and  the 
anterior  part  of  the  tibia.  Destruction  of  bone  and  tissue 
are  characteristic  of  this  stage. 

Perforated  Palate.— A  hard  swelling  in  the  roof  of  the 
mouth,  gradually  growing  larger,  becoming  deep  red  and 
then  softening  in  its  center  is  the  usual  course.  Gum- 
mata break  down  soon  if  treatment  is  not  started.  Per- 
foration of  the  hard  palate  into  the  nose  is  common  and 
this  decidedly  interferes  with  speech.  The  writer  has 
frequently  seen  such  an  opening  filled  up  by  the  patient 
with  gum  or  gauze  or  some  other  contrivance  so  as  to 
make  speech  intelligible.  Where  perforation  of  the  hard 
palate  occurs  an  artificial  denture  restores  speech  at  once. 
Ulcerations  and  swelling  are  always  suspicious.  Other 
symptoms  may  be  found.  The  result  of  a  broken-down 
gumma  is  a  deep  punched  out  ulcer  with  sloughing  in 
its  center. 

Perforated  Nasal  Septum.— The  septum  of  the  nose  is 
frequently  involved  and  the  junction  of  the  vomer  and 
the  cartilage  is  where  gumma  and  perforation  occur. 
When  at  this  point  is  found  an  irregular  perforation  of 


SYPHILIS  OF  THE  MOUTH 


353 


the  septum  involving  bone  and  cartilage,  one  may  be 
pretty  sure  it  is  syphilis  unless  there  has  been  an  opera- 
tion on  the  septum.  If  the  perforation  is  due  to  caustics 
or  picking  the  nose,  the  opening  is  more  apt  to  be  at 
the  center  of  the  cartilage  and  be  round  and  not  irregu- 
lar.   That  is  an  important  differentiation. 

Uvula  Involved. — The  soft  palate  and  uvula  are  fre- 
quently ulcerated.  The  effect  on  the  voice  is  the  same 
as  that  of  cleft  palate  if  the  palate  is  de- 
stroyed. If  the  uvula  and  also  a  portion 
of  the  soft  palate  are  destroyed  there  re- 
sult a  permanent  deformity  and  cicatrix 
which  interfere  considerably  with  the 
functions  of  the  soft  palate  and  the  clear- 
ness of  the  voice. 

Typical  Scar. — Stellate  and  puckered 
scars  often  indicate  the  loss  of  tissue 
from  syphilitic  ulcers.  This  is  quite 
characteristic.  It  is  surprising  how 
much  destruction  of  soft  or  bony  tissue 
can  take  place  in  a  very  short  time. 

Saddleback  Nose.— Figure  155  shows 
a  typical  deformity  of  the  nose.  A 
man  may  get  this  condition  as  the 
result  of  hereditary  or  contracted  syph- 
ilis. The  bones  and  tissues  are  so  de- 
stroyed that  support  for  the  bridge  of 
the  nose  is  lost  and  a  contraction  occurs.  The  nasal  bones 
may  not  be  injured  but  a  slumping  of  the  nose  may  re- 
sult from  destruction  of  the  tissues  at  the  junction  of  the 
cartilage  and  the  vertical  plate  of  the  ethmoid.  It  is  well 
to  remember  that  one  may  find  a  similar  condition  as  the 
result  of  an  improper  submucous  resection  operation. 
Slumping  or  sagging  of  the  tip  of  the  nose  from  this  op- 
eration is  quite  common.  There  may  also  be  a  saddleback 
nose  due  to  injury  of  the  nose  with  abscess  formation; 
this  may  be  unrecognized  and  go  on  to  destruction  of  the 


Fig.  155. — Saddle- 
back Nose. 


354 


VUNEREAL  DISEASES 


cartilage  and  bone  with  a  resulting  depression  of  the 
bridge. 

The  dentist  should  always  be  suspicious  of  a  slumping 
nose.  He  must  find  out  if  operation  on  the  septum  has 
taken  place  or  if  the  patient  has  had  a  severe  nasal  in- 
jury with  abscess  formation. 

The  patient  shown  in  Figure  156  came  to  the  writer's 
attention  with  the  whole  interior  of  the  nose  destroyed, 
the  septum  completely  eaten  out,  the  turbinates  largely 


Fig.  156. — Syphilis  of  Nose. 


destroyed,  even  the  frenum  gone.  Just  one  great  cavity 
remained.  The  sides  of  the  nose  had  begun  to  show  a 
slight  contraction.  This  was  the  result  of  improper  treat- 
ment, or  neglect  of  treatment.  With  good  treatment 
syphilitic  manifestations  usually  readily  yield.  De- 
stroyed tissue  cannot  be  replaced.  Ulcerations  may  be 
made  to  heal  but  scars  remain  as  telltales. 

Syphilis  is  frequently  manifested  in  the  nasal  sinuses, 
especially  the  antrum  and  the  ethmoidal  cells.  The  fron- 
tal bone  (see  Fig.  157)  just  above  the  frontal  sinuses  is 
sometimes   the   situation   of  gummata  which   look  like 


SYPHILIS  OF  THE  MOUTH 


355 


little  horns.  At  first  they  are  indurated,  if  allowed  to 
break  down  and  discharge,  a  disagreeable  ulcer  is  formed, 
hard  to  heal  and  with  a  deforming  scar.  They  should 
not  be  incised,  for  they  yield  readily  to  iodid  of  potash 
or  mercury. 

Necessary  Evidence. — The  frequent  testing  of  blood  is 
now  very  important  in  clearing  up  doubtful  diagnoses. 
One  negative  Wassermann,  especially  if  mercury  has 
been  used,  is  not  always  satisfactory  evidence.  Lips  with 
slow  healing  ulcers  at  the  angle  of  the  mouth  are  sus- 
picious. They  are  not  always 
cold  sores.  Corroborative 
evidence  must  be  sought.  A 
diagnosis  cannot  be  made 
from  one  symptom.  Mucous 
patches,  general  adenopathy, 
headaches,  more  or  less  fall- 
ing of  the  hair,  pains  in  the 
bones  or  head  late  in  the  af- 
ternoon and  skin  lesions  are 
the  corroborative  evidence  to 
look  for. 

One  would  not  like  to  be  the 
father  of  a  youngster  like 
the  one  in  the  illustration.  Figure  158  shows  a  typical 
hereditary-syphilitic  child.  The  condition  of  the  eyes, 
the  old-man  look  and  wrinkled  skin  are  noticeable. 

Hutchinsonian  Teeth. — Hutchinsonian  teeth  are  quite 
characteristic  of  hereditary  syphilis.  These  teeth  ought 
to  be  well  known  to  the  profession.  The  cupping  of  the 
central  incisors  and  the  laterals,  also  the  pegged  shape 
of  the  teeth  are  quite  diagnostic. 

The  patient  shown  in  Figure  159  came  into  the  author's 
office  one  afternoon.  The  diagnosis  was  plain  because  of 
the  cupping  and  pegging  of  the  teeth,  also  the  slumping 
nose.  The  mother  had  syphilis  and  the  child  was  syphi- 
litic by  heredity.    The  Hutchinsonian  teeth,  the  slumping 


Fig.   157. — Syphilitic  Nodes  of 
the  Skull. 


356 


VENEREAL  DISEASES 


nose,  the  general  glandular  enlargement,  and  the  lack 
of  proper  development  are  some  of  the  evidences  in  this 
case. 


Fig.  158. — Hereditary  Syphilis. 


This  leads  the  writer  to  say  that  treatment  for  syphilis 
should  not  be  begun  until  an  absolute  diagnosis  has  been 
made.  The  therapeutic  test,  while  it  may  relieve  the 
patient,  hides,  and  sometimes  leaves  a  doubt  whether  a 


DISEASES  OF  THE  MOUTH 


357 


correct  diagnosis  has  been  made,  so  that  neglect  of  treat- 
ment results.  In  the  absence  of  absolutely  characteristic 
symptoms,  the  demonstration  of  the  Spirocheta  pallida 


Fig.  159. — Hutchinsonian  Teeth. 


or  the  positive  serological  test  is  very  desirable.  Syph- 
ilis simulates  many  other  diseases,  therefore  it  is  wise  to 
have  in  mind  the  more  common  diseases  having  mani- 
festations around  the  mouth. 


DISEASES  OF  THE  MOUTH  SIMULATING  SYPHILIS 


Herpes  Labialis.— This  lesion  is  quite  different  from 
syphilis.  Vesicles  appear  on  the  lips,  with  more  or  less 
pain ;  these  coalesce  and  in  a  few  clays  disappear,  leaving 
no  scars.  Syphilitic  lesions  are  slow  in  origin,  usually 
without  pain,  and  tend  to  advance  and  destroy  tissue 
unless  constitutional  treatment  has  been  instituted. 

Stomatitis.— This  condition  is  also  rapid  in  its  course. 
There  is  a  vesicle  which  enlarges  and  bursts,  leaving  a 
cup-shaped  ulcer  with  a  red  zone  of  inflammation  around 


358 


VENEREAL  DISEASES 


Fig.   160. — Geographic 
Tongue. 


it.     The  ulcer  is  often  very  painful.     This  usually  lasts 
but  a  few  days. 

Vincent's  Angina.— This  disease  is  apt  to  be  mistaken 
for  syphilis ;  a  sloughing  irregular  ulcer  of  one  or  both 

tonsils,  tending  to  deepen  in  the 
tissues,  sometimes  causing  foul 
breath  and  pain  and  local  glandu- 
lar enlargement.  The  low-power 
microscope  shows  the  Bacillus  fu- 
siformis  and  the  Spirocheta  refrin- 
gens.  The  Wassermann  test  is 
negative. 

A  positive  Wassermann  is  here 
of  great  importance.  A  negative 
Wassermann  is  interesting  but  not 
always  to  be  relied  on. 

Geographic  Tongue  or  Wan- 
dering Rash.  — This  is  a  superficial  denudation  of  the 
epithelium,  leaving  a  red  base  surrounded  by  white  edges, 
serpiginous  in  form.     This  is  not  syphilis. 

Leukoplakia.— Sometimes  there  is  a  tongue  that  looks 
as  if  it  had  been  coated  with  white 
paint.  This  symptom  also  some- 
times appears  on  the  inner  side  of 
the  cheek  near  the  angle  of  the 
mouth.  This  is  leukoplakia.  It  is 
often  seen  in  excessive  smokers, 
sometimes  associated  with  syphi- 
lis, sometimes  a  precursor  of  can- 
cer. 

Tubercular  Ulcers. — These  ul- 
cers may  invade  the  mouth,  lips 
or  larynx.  The  process  is  slow;  tubercles  forming  and 
breaking  down  into  superficial  ulcerations,  producing  a 
more  or  less  moth-eaten  appearance.  These  ulcers  are 
indolent,  hard  to  heal  and  slow  to  advance. 

Carcinoma  of  Tongue  or  Mouth.— Cancer  has  always 


Fig.    161. — Leukoplakia. 


DISEASES  OF  THE  MOUTH  359 

to  be  considered  when  making  a  diagnosis  of  syphilis. 
It  presents  a  sloughy  surface,  deep  red  or  purple,  bleed- 
ing easily,  usually  associated  with  lancinating  pain.  It 
progresses  slowly,  involves  all  tissues  and  produces  ca- 
chexia in  the  advanced  stages.  It  is  rarely  seen  under 
the  fortieth  year.  Swelling,  fetid  breath,  and  enlarge- 
ment of  the  neighboring  cervical  glands  are  other  symp- 
toms. Cancer  and  syphilis  may  coexist  in  the  same  per- 
son. 

Tonsillitis.— This  condition  is  one  of  the  most  frequent 
diseases  which  the  soldier  contracts.    Close  quarters,  ill 
ventilation,  dampness,  fa- 
tigue and  exposure  favor 
it.      It    sometimes    seems 
epidemic      in      character. 
There  has  been  a  recent 
example  in  its  prevalence 
at  the  Ship  at  Marblehead. 
It    is    very    common    in 
young  adult  life.     It  be- 
gins with  swelling  of  one        Fig.  162.— Carcinoma  of  Tongue. 
or    both    tonsils,    malaise 

and  headache,  high  temperature  and  rapid  pulse.  With 
the  swelling  occur  fever  and  difficulty  in  swallowing;  the 
tonsils  have  a  white  exudate  usually  coming  from  the 
crypts.  The  attack  lasts  from  three  to  ten  days,  leav- 
ing the  patient  weak  and  exhausted.  Rheumatism,  ne- 
phritis and  heart  complications  frequently  follow  an  at- 
tack of  this  kind.  The  patient  may  apparently  start  to 
get  well  in  a  few  days,  when  the  symptoms  return  and 
become  localized  in  one  side  of  the  throat. 

Quinsy  or  Peritonsillar  Abscess.— This  condition  is  a 
result  of  tonsillitis.  It  is  an  inflammation  of  the  tissues 
around  the  tonsils  which  forms  an  abscess  in  the  supra- 
tonsillar  fossa.  As  soon  as  fluctuation  can  be  determined, 
an  incision  should  be  made  to  let  out  the  pus.  The  pa- 
tient should  not  be  allowed  to  suffer  until  the  pus,  trying 


360  VENEREAL  DISEASES 

to  get  out,  breaks  into  the  throat.  Pus  always  burrows 
in  the  line  of  least  resistance.  Opiates  are  contra-indi- 
cated, for,  if  the  abscess  ruptures,  there  is  great  danger 
of  suffocation  or  septic  pneumonia  resulting.  If  the  pa- 
tient has  one  quinsy,  he  is  very  likely  to  have  another 
attack.  It  is  best  to  have  the  tonsils  removed  to  save 
further  trouble. 

Diphtheria. — In  some  of  the  camps  diphtheria  has 
broken  out.  A  distinct  membrane  appears  on  the  tonsil, 
in  the  nose  or  larynx — somewhere  in  the  upper  air  pas- 
sages. It  is  attended  with  slight  fever  at  first.  The  mem- 
brane rapidly  spreads  over  the  tonsils  or  adjoining  tis- 
sue ;  it  is  not  confined  to  the  tonsils  as  in  tonsillitis.  The 
membrane  is  adherent,  bleeds  easily;  if  removed  it  soon 
returns.  Cultures  should  be  taken  whenever  a  doubtful 
exudate  is  seen  in  the  nose  or  throat,  for  antitoxin,  which 
has  proven  of  wonderful  value  in  curbing  this  disease, 
must  be  used  early  to  obtain  the  best  results.  Every 
day  lessens  its  chance  of  curing.  With  a  mortality  re- 
duced from  forty  or  fifty  per  cent  down  to  one  or  two 
per  cent,  the  great  dread  of  this  disease  is  lessened. 
Early  diagnosis  is  all-essential. 

Hypertrophied  Tonsils.— There  can  be  no  doubt  that 
tonsils  are  enlarged,  which  extend  into  the  throat,  almost 
meeting  in  the  median  line.  But  sometimes  tonsils  which 
do  not  appear  large  are  held  back  into  the  tonsillar  space 
by  a  little  fold  of  membrane  called  the  plica  triangularis. 
These  tonsils  are  frequently  more  dangerous  than  the 
obviously  very  large  ones.  If  an  individual  has  a  red  or 
sore  throat,  especially  if  the  crypts  of  the  tonsils  are 
filled  with  little  cheesy  masses;  if  he  has  had  quinsy  or 
enlarged  or  painful  cervical  glands,  the  writer  believes 
the  tonsils  should  be  removed  by  careful  enucleation. 
He  has  never  seen  harm  resulting,  but  has  frequently 
known  of  great  improvement  in  general  bodily  health  and 
relief  of  so-called  rheumatic  or  neuritic  pains.    Inflam- 


THE  NOSE  361 

mation  of  the  tonsils  is  many  times  followed  by  cardiac 
and  nephritic  complications,  therefore  one  seldom  errs 
in  removal,  providing  it  is  done  completely. 

Tonsillectomy.— This  and  not  tonsillotomy,  should  be 
the  operation  of  choice.  The  latter  operation  is  often 
the  cause  of  serious  complications  because  of  its  incom- 
pleteness. Asepsis,  as  in  all  operations,  should  be  the 
rule.  If  the  patient  has  adenoids,  they  should  be  re- 
moved at  the  same  time  as  the  tonsils.  While  the  opera- 
tion can  be  done  with  local  anesthetics,  the  writer  be- 
lieves it  should  always  be  done  under  general  anesthesia 
and  ether  is  the  best  agent.  It  is  safe  and  gives  plenty 
of  time  to  go  slowly,  split  the  capsule  and  not  injure 
the  pillars  of  the  fauces.  Fatal  or  serious  hemorrhage 
has  resulted  from  this  operation,  but  in  careful,  skilled 
hands  such  an  accident  is  rare. 

The  capsule-splitting  operation  is  practically  bloodless* 
When  a  case  has  been  operated  on  before,  it  is  more  dif- 
ficult to  do  a  good  tonsillectomy  because  of  adhesions. 
The  writer  believes  it  helps  healing  to  paint  the  cut  sur- 
face, which  is  left,  with  iodin  or  iodin  and  tincture  of  ben- 
zoin. A  week  to  ten  days  is  the  time  it  takes  the  throat 
to  heal  after  tonsillectomy.  Rest  and  soft  food  for  a 
few  days,  catharsis  with  castor  oil  or  cascara  sagrada 
(not  salts)  is  the  after  treatment.  After  tonsillectomy 
the  soreness  is  more  severe  than  following  tonsillotomy. 
A  white  exudate  forms  over  the  cut  surface ;  this  is  nor- 
mal and  gradually  disappears  as  the  throat  heals. 

THE  NOSE 

Injuries  and  Diseases  of  Nose 

The  nose  is  the  most  prominent  portion  of  the  face  and 
is  made  up  of  cartilage,  bone  and  integument.  It  is  fre- 
quently injured  because  of  its  prominence.  If  the  tis- 
sues are  injured  or  torn,  as  much  must  be  saved  as  possi- 


362  VENEREAL  DISEASES 

ble.  Thus  cleaned  and  restored  an  ugly  deformity  may 
be  prevented.  When  the  bones  of  the  nose  are  fractured, 
a  dislocation  is  very  apt  also  to  occur.  If  not  replaced 
at  once  and  held  in  position  until  union  takes  place,  con- 
siderable deformity  may  result,  often  unsightly  and  an- 
noying to  the  victim. 

Fracture  of  Nasal  Bones.— A  face  mask  was  used  in 
recent  work  in  the  orthodontia  school  of  the  Forsyth  In- 
firmary. The  patient,  a  young  man,  received  a  crushing 
blow  on  the  bridge  of  the  nose,  fracturing  and  dislocat- 
ing the  nasal  bones  and  septum,  causing  a  spreading 
and  separation  of  the  bridge  as  well  as  a  slumping  and 
marked  interference  with  nasal  breathing.  He  was  quite 
unhappy  because  of  the  ill-shaped  nose.  The  writer  pro- 
posed then  to  refracture  the  nasal  bones  along  their  base 
and  set  up  the  nose,  holding  it  in  place  by  intranasal  plugs 
and  an  external  splint  or  plaster  cast.  The  time  to  have 
best  fixed  this  was  immediately  after  the  injury.  Then 
the  parts  were  pliable  and  easy  to  hold  in  proper  posi- 
tion. Physicians  too  often  stop  the  nose-bleed  and  say 
the  swelling  will  go  down,  without  even  trying  to  deter- 
mine whether  the  bones  are  fractured  or  if  the  interior  of 
the  nose  has  been  damaged.  That  becomes  evident  later 
when  it  is  too  late  to  be  easily  remedied.  If  one  does 
not  get  proper  support  for  the  slumping  condition,  one 
must  later  insert  a  piece  of  rib  or  edge  of  the  tibia  to  re- 
store the  fallen  bridge.  If  the  deformity  is  slight  paraffin 
may  be  used. 

Epistaxis.  — Nose-bleed  is  so  very  common  that  every- 
one should  know  how  to  stop  it.  The  bleeding  point  usu- 
ally is  on  the  septum,  it  may  be  the  turbinates.  About 
one-half  to  one  inch  from  the  vestibule  there  is  a  plexus 
of  veins  on  the  septum  near  the  surface  and  easily  rup- 
tured by  trauma  or  picking.  Usually  a  firm  plug  of  gauze 
or  cotton  placed  well  within  the  bleeding  nostril  and  held 
there  for  a  short  time  will  stop  the  hemorrhage.     One 


THE  NOSE  363 

must  not  keep  pulling  the  plug  out  to  see  if  the  bleeding 
has  stopped.  A  chance  for  a  firm  clot  to  form  is  neces- 
sary. Sometimes  one  must  moisten  the  cotton  with  ad- 
renalin chlorid,  hydrogen  peroxid  or  Monsel  solution.  Ir- 
rigation of  the  nose  with  hot  normal  salt  solution  (110°- 
115°)  is  very  helpful  in  stopping  hemorrhage.  Only 
rarely  is  it  necessary  to  insert  a  postnasal  plug. 

Control  of  Hemorrhage  from  Nose. — If  the  bleeding 
point  cannot  be  found  and  hemorrhage  is  profuse,  refus- 
ing to  stop  by  the  milder  methods  suggested,  then  one 
may  use  a  Bellocq  sound  or  catheter  with  stylette,  carry- 
ing a  string  through  the  nostril  to  the  nasopharynx  and 
into  the  back  part  of  the  mouth.  A  piece  of  gauze  about 
the  size  of  the  thumb  is  then  tied  on  to  the  string  on  the 
mouth  end.  The  nasal  end  of  the  string  is  then  gently 
pulled  and  the  gauze,  guided  by  the  finger,  is  carried  into 
the  postnasal  space  and  tight  into  the  nares  from  which 
the  blood  is  escaping.  The  anterior  nares  may  then  be 
plugged.  In  this  way  both  ends  of  the  nasal  passage  may 
be  securely  closed.  Coagulo-plastin  or  rabbit  serum  may 
be  used  in  severe  hemorrhages.  Sometimes  tannic  acid 
or  gallic  acid  may  be  used  on  the  gauze.  It  is  rare,  how- 
ever, that  a  nasal  hemorrhage  may  not  be  stopped  by 
careful  packing,  using  a  nasal  speculum  and  gauze  one 
inch  wide  and  thirty-six  inches  long.  This  may  be  packed 
into  the  nose,  in  the  posterior  portion  first  and  gradually 
forward.  Properly  done,  usually  no  other  medication  but 
the  even  pressure  of  the  gauze  is  all  that  is  required. 
The  nasal  packing  should  not  be  left  in  the  nares  more 
than  forty-eight  hours.  It  is  better  less.  If  there  is  high 
blood  pressure,  it  must  be  reduced  by  bromid  or  morphia. 
Recurrent  epistaxis  is  best  treated  by  cauterizing  the 
bleeding  point  with  chronic  acid,  nitrate  of  silver  or  the 
actual  cautery. 

Bumps  on  the  nose  are  not  simple  affairs.  After  stop- 
ping the  hemorrhage  which  usually  takes  place,  it  must 


364  VENEREAL  DISEASES 

be  noted  whether  the  thin  nasal  bones  are  fractured  or 
dislocated. 

Hematoma  and  Abscess  of  the  Septum.— Sometimes  as 
the  result  of  injury  the  nose  is  found  blocked  with  a 
dark  red  fluctuating  swelling  on  one  or  both  sides  of  the 
septum.  There  has  been  an  extravasation  of  blood  into 
the  tissues  and  a  blood  tumor  or  hematoma  results.  A 
free  incision  at  the  most  dependent  portion,  on  one  side 
only,  must  be  made  early  and  the  clot  of  blood  turned 
out.  Otherwise  the  blood  breaks  down,  forming  an  ab- 
scess, and  very  soon  both  cartilage  and  bone  are  de- 
stroyed. A  fluctuating  swelling  is  seen  involving  both 
nares,  pale  in  color,  with  or  without  pain  and  interfer- 
ing with  nasal  breathing.  Unless  this  abscess  is  in- 
cised, the  pus  burrows  in  the  line  of  least  resistance, 
finally  breaks  through  and  discharges.  Considerable  dam- 
age to  bone  or  cartilage  takes  place  with  deformity  as  the 
result  of  contraction  and  scar  formation.  The  abscess 
should  be  opened  at  once  at  the  lowest  point  and  drainage 
kept  up  until  well.  In  this  way  one  may  avoid  ugly  de- 
formities of  the  nose. 

Acute  Rhinitis.— Of  the  diseases  of  the  upper  respira- 
tory tract,  acute  rhinitis  or  coryza  is  the  most  common. 
From  a  variety  of  causes  and  infections  one  gets  what  is 
sometimes  called  a  cold.  Sneezing,  stuffiness  of  the  nose, 
headache,  slight  fever,  profuse  watery  discharge  which 
lasts  three  to  ten  days,  follow.  Then  the  patient  gets 
well,  that  is,  the  mucous  flow  becomes  thicker  and  less, 
nasal  breathing  improves,  headaches  stop  and  the  dis- 
charge ceases.  The  patient  is  apparently  all  right  again. 
After  a  succession  of  these  attacks  chronic  changes  in  the 
tissues  of  the  nose  are  produced  and  a  constant  thick, 
more  or  less  yellowish  discharge  is  noticed,  requiring  fre- 
quent and  persistent  use  of  the  handkerchief  or  hawking 
and  spitting.  This  is  the  ordinary  chronic  rhinitis  or 
chronic  catarrh.  When  this  persists  there  is  a  third  form 
of  catarrh  which  is  called  atrophic  rhinitis,  characterized 


THE  NOSE  365 

by  roomy  nostrils  filled  with  crusty  secretion,  hard  to 
blow  out  or  remove  and  often  with  offensive  odor.  This 
condition  is  associated  with  the  loss  of  the  sense  of  smell 
and  taste.  It  requires  persistent  washings  to  relieve  the 
odor  and  crusts.  Atrophic  rhinitis  is  seldom  cured  when 
at  all  advanced. 

The  Nasal  Sinuses 

Connected  with  each  nasal  cavity  are  four  sets  of  sinu- 
ses or  bony  cavities,  (a)  the  frontal;  (b)  the  ethmoidal 
cells;  (c)  the  sphenoidal;  and  (d)  the  maxillary  sinuses. 
These  are  very  important  and  one,  the  maxillary  sinus  or 
antrum  of  Highmore,  is  especially  so  to  dentists.  They  all 
have  openings  connecting  directly  with  the  nasal  cham- 
bers and  they  are  lined  with  mucous  membrane  continu- 
ous with  the  nasal  cavities.  Any  pathological  condition 
in  the  nose  proper  is  likely  to  invade  the  sinuses;  thus 
there  is,  by  extension  from  the  nose,  sinus  disease,  which 
may  be  acute  or  chronic.  As  the  acute  inflammation  in 
the  nose  subsides,  so  it  does  in  the  sinuses,  and  normal 
ventilation  and  drainage  of  the  sinuses  is  restored.  In 
other  words,  usually  the  acute  cases  get  well  as  the  nasal 
symptoms  subside.  Sometimes  pain  and  discharge  of  pus 
continues  from  one  or  both  nares.  It  is  important  to  find 
where  it  comes  from.  Retention  of  pus  always  means 
pain — the  situation  of  the  pain  is  often  a  guide  to  the 
sinus  involved,  or  if  the  openings  of  the  sinuses  are  large 
enough  to  allow  vent,  then  the  position  of  the  pus  in  the 
nasal  chamber  directs  to  the  sinus  affected. 

X-ray  Diagnosis.— The  X-ray  is  an  important  aid  in 
diagnosis,  as  is  also  transillumination.  The  latter  is  of 
greatest  value  in  disease  of  the  maxillary  sinuses,  which 
are  the  largest  and  perhaps  most  often  affected  because 
they  may  be  diseased  from  nasal  infections  or  from  bad 
teeth.  The  upper  second  bicuspid  and  the  first  and  sec- 
ond molars  it  must  be  remembered  are  the  teeth  nearest 
to  the  floor  of  the  antrum  and  most  likely  to  be  the  cause 


366 


VENEREAL  DISEASES 


of  antral  disease.  An  X-ray  is  important  in  showing  the 
condition  of  the  apices  of  these  teeth  and  their  relation 
to  the  antrum.  A  unilateral  discharge  of  pus  from  the 
nose  in  an  adult  means  sinus  disease.  A  discharge  of 
offensive  pus  from  the  nose  is  most  likely  to  be  from  the 
antrum  and  of  tooth  origin.    If  there  is  a  carious  and  ten- 


Fig.  163. — Operation  on  Antrum.     (Coakley.) 

der  second  bicuspid  or  first  or  second  molar  associated 
with  a  unilateral  pus  discharge  from  the  nose,  it  is  prob- 
able there  is  an  involvement  of  the  antrum.  Transillu- 
mination is  very  helpful  in  making  the  diagnosis.  If  a 
tooth  is  the  cause  extract  it ;  then  the  socket  may  be  en- 
larged and  the  antrum  washed  out  through  the  tooth 
socket  with  normal  salt  solution.  If  an  offensive  pus  is 
found  in  the  washings,  they  may  be  continued  daily  for 
a  few  days.     The  condition  will  probably  get  well  soon. 


THE  NOSE 


367 


It  is  well  never  to  be  rough  with  the  mucous  membrane 
lining  the  antral  wall. 

Operation  on  Antrum.— If  the  cavity  has  been  washed 
many  times  without  improvement,  a  radical  operation  is 
usually  indicated.  Sometimes  the  removal  of  the  anterior 
end  of  the  middle  turbinated  bone  will  allow  the  neces- 
sary ventilation  and  drainage  of  the  nares  and  the  pa- 


Figs.    16-4   and   165. — Luc   Caldwell   Operation. 


tient  may  get  well  without  a  more  extensive  operation. 
If  the  antrum  is  a  reservoir  for  collection  of  pus  from 
the  frontal  and  ethmoidal  cells,  these  must  be  cured  be- 
fore one  can  expect  the  antrum  to  get  well.  If  the  teeth 
are  apparently  in  good  condition  and  the  antrum  is  dis- 
eased, it  is  not  advisable  to  sacrifice  the  teeth,  but  open 
into  the  antrum  through  the  lower  meatus  of  the  nose.  A 
large  opening  can  be  made  without  doing  any  permanent 
damage  and  frequent  washings  may  easily  be  accom- 
plished.   This  is  done  by  pushing  a  large  troehar  directly 


368 


VENEREAL  DISEASES 


through  the  nasal  wall  under  the  inferior  turbinate  as 
shown  in  Figure  163.  Sometimes  the  antral  lining  is  so 
diseased  that  a  radical  operation  at  the  gingivolabial 
margin  above  the  teeth  is  the  only  method  of  cure.  The 
antrum  may  be  completely  explored  in  this  way,  enough 
of  the  antral  wall  being  taken  away  to  insert  the  finger 
and  curette  throughout  the  whole  of  the  sinus.     It  is 

better  to  make  at  the 
same  time  an  opening 
through  into  the  nose  and 
after  cleansing  the  cavity 
pack  the  antrum  with 
gauze,  leaving  an  end 
hanging  from  the  nostril. 
The  original  incision  may 
be  closed  up  by  interrupt- 
ed sutures  and  the  treat- 
ment thereafter  is 
through  the  nose.  The 
packing  is  removed  in 
forty-eight  hours.  Usual- 
ly results  are  very  satis- 
factory {see  Figures  164 
and  165).  It  is  called  the 
Luc  Caldwell  antrum  op- 
eration. 

Figure  166  shows  the  more  radical  or  Denker  operation 
on  the  antrum  of  Highmore  which  is  sometimes  neces- 
sary. There  is  occasionally  a  little  pocket  at  the  anterior 
portion  of  the  sinus  which  keeps  up  discharge,  and  re- 
moval of  this  portion  of  the  maxillary  bone  is  necessary. 
The  antral  and  nasal  cavity  are  here  made  into  one. 
There  may  be  a  slight  deformity  from  this  operation. 
There  is  none  from  the  Luc  Caldwell. 

A  unilateral  pus  discharge  from  the  nose  of  a  child 
means  a  foreign  body  in  the  nares,  in  an  adult  usually 
some  sinus  involvement.    If  the  patient  with  discharge 


Fig.  166. — Denker  Operation. 


MEASLES  AND  MUMPS  369 

from  the  nose  is  conscious  of  odor,  it  is  probably  from 
one  of  the  sinuses,  but  if  those  around  him  perceive  the 
odor,  it  is  probably  from  a  chronic  or  atrophic  rhinitis. 


MEASLES  AND  MUMPS 

A  recent  visit  to  the  naval  hospital  in  Chelsea  dis- 
closed the  fact  that  there  were  two  diseases  quite  preva- 
lent :  measles  and  mumps.  These  two  conditions  have 
been  quite  common  in  other  sections.  The  danger  from 
measles  is  in  its  secondary  involvements:  ears,  eyes,  or 
lungs.  Acute  middle  ear  inflammation  is  frequent  and 
demands  an  early  paracentesis,  or  else  rupture  of  the 
drum  membrane  will  result  with  considerable  damage  to 
the  hearing,  besides  leaving  a  chronic  running  ear.  In 
adults  mumps  or  parotitis  amounts  to  very  little  if  the 
patient  is  kept  warm  and  quiet  for  a  few  days.  Some- 
times it  descends  into  the  testicles,  causing  orchitis.  This 
is  painful  and  may  result  in  sterility. 

Parotid  and  Submaxillary  Glands 

Inflammation  of  Wharton's  Duct. — Sometimes  the  sub- 
maxillary outlet  or  Wharton's  duct,  which  lies  close  un- 
der the  tongue  and  empties  at  the  frenum  under  the 
tip  of  the  tongue,  becomes  blocked.  The  duct  seems  hard 
like  a  pipestem  and  the  gland  is  swollen  and  tender. 
There  is  an  interference  with  the  flow  of  salivary  fluid 
through  the  affected  duct.  This  condition  is  found  many 
times,  and  is  due  to  a  salivary  calculus  forming  some- 
where in  the  duct  near  the  exit  or  well  down  toward  the 
gland ;  it  may  be  very  small  or  quite  long  and  large.  One 
removed  a  short  time  ago  is  one  and  one-half  inches  in 
length.  Sometimes  inflammation  of  the  duct  is  produced 
and  pus  may  be  seen  coming  from  the  opening  near  the 


,370  VENEREAL  DISEASES 

frenum.     Incision  along-  the  duct  until  the  calculus  is 
reached  and  freed  is  the  treatment. 

Sometimes  the  tongue  is  pushed  up  and  speech  inter- 
fered with  by  a  painless  swelling.  There  may  be  con- 
siderable drooling  of  saliva  but  no  inflammation.  The 
tumor  is  bluish  white  and  translucent.  This  is  a  ranula 
or  a  blocking  of  one  of  the  ducts  of  Rivinus,  with  cyst 
formation.  The  contents  are  just  like  the  white  of  an 
ogg  and  the  sac  wall  is  very  thin.  Dissection  of  the  sac 
is  therefore  not  easy,  it  usually  ruptures  before  com- 
pletely exposed  and  immediately  collapses.  However, 
as  much  of  the  sac  as  possible  must  be  removed  and  the 
cavity  packed  so  as  to  stimulate  granulation,  otherwise 
it  returns.  Evacuation  of  the  contents  does  no  perma- 
nent good. 

PROPER  BREATHING 

Good  nasal  breathing  is  a  necessity  for  good  health 
and  for  physical  and  mental  development;  this  is  now 
well  recognized.  Nature  has  equipped  the  nasal  passages 
so  that  air  may  be  properly  prepared,  while  passing 
through  the  nose,  for  its  reception  into  the  delicate  lungs. 
The  air  is  here  strained  of  dust  and  germs,  warmed  to 
body  heat  and  saturated  with  moisture.  If  a  man  is  a 
mouth-breather,  the  body  suffers  because  the  air  cannot 
be  properly  warmed,  moistened  and  strained.  One  has 
only  to  breathe  through  the  mouth  a  few  times  to  see  how 
dry  the  mucous  membrane  becomes.  The  secretion  of 
the  mouth  is  different  from  that  of  the  nose.  Its  func- 
tion is  to  start  digestion  and  to  make  a  bolus  of  food 
which  may  be  easily  pushed  on  into  the  esophagus.  Any- 
thing in  the  nose  which  prevents  a  free  current  of  air 
through  it  also  interferes  with  the  sense  of  smell  and 
taste.  Secretion  from  acute  or  chronic  rhinitis  and  from 
sinus  affections  more  or  less  interferes  with  the  ventila- 
tion and  drainage  of  the  nose,  so  do  new  growths.    Espe- 


PROPER  BREATHING 


371 


cially  common  are  pol}rps,  which  probably  are  the  result 
of  a  chronic  inflammation  of  the  ethmoidal  cells. 


Fig.  167. — Nasal  Polyps.     (Coakley.) 

Polyps  may  be  removed  by  the  cold  wire  snare  or  by 
forceps.    They  are  apt  to  return  again. 


Causes  of  Mouth-Breathing 

The  common  cause  of  mouth-breathing  in  the  adult  is 
a  deviated  septum ;  this  is  closely  associated  with  irregu- 
lar development  of  the  teeth  and  the  upper  dental  arch. 
In  fact,  the  whole  development  of  the  face  depends 
largely  on  early  breathing  habits.  Mouth-breathing 
caused  by  chronic  catarrh,  adenoids,  or  habits  if  these 
have  been  removed,  is  frequent.  The  balance  of  muscle 
forces  of  the  face  is  upset,  resulting  in  a  change  in  muscle 
action  during  early  second  dentition.  It  is  in  this  plastic 
and  formative  period  of  development  of  the  face  that  the 
bones  are  molded  into  a  different  shape  than  nature  in- 


372 


VENEREAL  DISEASES 


tended,  thus  making  nose-breathing  difficult  or  impos- 
sible in  later  life.  The  nose,  from  lack  of  use,  does  not 
broaden ;  the  maxillary  arch  becomes  high  and  the  teeth 
irregular  and  the  whole  dental  arch  is  narrowed  and 
elongated.  When  the  child  is  twelve  or  fourteen  these 
deformities  become  hard  to  correct,  and  in  adult  life  can- 
not be  made  normal,  for  the  bones  are  then  fixed  and  un- 
changeable. 

Deviated  Nasal  Septum.— Trauma  and  irregular 
growth  are  the  causes  of  deviated  septal  deformities. 

They  are  not  in  evidence  be- 
fore the  seventh  year  as  a 
rule,  but  with  growth  be- 
come more  pronounced  or 
obstructive.  They  vary 
much  in  shape.  Sometimes 
a  small  deviation  causes 
more  marked  symptoms  of 
obstruction  than  a  fairly 
large  one.  The  narrowness 
of  the  nostrils  and  the 
amount  of  nasal  discharge 
are  important  in  causing 
symptoms.  Even  though  all 
obstructions  in  the  nose 
may  be  removed  or  corrected,  the  individual  may  still  be 
a  mouth-breather  because  of  malformation  and  uncor- 
rected habits.  A  deviated  septum  makes  one  short- 
breathed  on  exertion.  Submucous  resection  of  the  sep- 
tum is  the  only  operation  that  gives  satisfactory  results 
in  correcting  deviations  of  the  septa,  thus  restoring  the  lu- 
men of  the  nose  approaching  normal. 

Submucous  Operation.— This  may  be  performed  under 
ether  or  by  means  of  novocain  and  adrenalin.  The  latter 
is  preferable,  as  it  is  bloodless ;  the  pain  during  the  oper- 
ation is  entirely  bearable  and,  as  soon  as  it  is  over,  the 
patient  may  go  home.    There  is  no  disagreeable  vomit- 


Fig.  168. — Deviated  Septum. 


Figs.  169  A,  B—  Stages  of  Technic  11;  Submucous  Resection  of  De- 
viated Nasal  Septum. 
373 


Figs.  169  C,  D._ Stages  of  Technic  in  Submucous  Eesection  (Continued). 

374 


PROPER  BREATHING 


375 


ing  which  increases  the  discomfort  of  the  nasal  pings, 
which  are  usually  inserted  to  keep  the  septal  mucous 
membrane  together  after  the  operation  for  from  twelve 
to  twenty-four  hours.  The  patient  is  able  to  return  to 
work  in  a  few  days  and  in  ten  days  the  nose  is  well.  In 
most  cases  nasal  respiration  is  much  improved  and  the 
comfort   in  breathing  during  sleep  is   very  noticeable. 


Fig.  170. — Extent  of  Septal  Removal  Necessary  to  Equalize  the 
Nostrils  and  Promote  Normal  Ventilation. 

Many  times  patients  have  said  that  their  mentality  has 
wonderfully  improved  following  operation,  because  of 
the  freer  inspiration. 

Bibliography 

Havaed.     Military  Hygiene. 

Coakley.     Diseases  of  the  Nose  and  Throat. 

Phillips.     Diseases  of  the  Ear,  Nose  and  Throat, 

Gruxwald.     Mouth,  Pharynx  and  Nose. 

Butlix.     Diseases  of  the  Tongue. 

Graxt.     Surgical  Diseases  of  the  Face. 


CHAPTER  XIV 

APPEARANCES  OF  THE  MOUTH  IN  SOME  OF  THE 
COMMON  INFECTIOUS  DISEASES 

Howard  Smith,  M.D. 

In  speaking  of  infective  diseases  it  is  necessary  to 
presuppose  a  general  knowledge  of  medical  terms.  The 
writer  will  select  three  or  four  of  the  most  important 
of  such  diseases  and  then  speak  briefly  on  these.  In  a 
book  of  this  kind  it  would  be  impracticable  to  give  all 
the  points  regarding  the  treatment,  diagnosis,  and  so 
forth,  of  these  different  troubles.  But  fortunately  for  the 
purpose  of  this  chapter  most  of  these  diseases  have  cer- 
tain manifestations  in  the  mouth  by  which  they  may  be 
diagnosed,  and  the  point  in  treating  of  these  different 
conditions  is  not  that  the  dentist  may  be  expert  in  treat- 
ing them  or  that  he  expects  to  treat  them,  but  that  he 
may  be  on  his  guard  and  recognize  the  early  symptoms 
if  they  develop. 

Danger  of  Infective  Disease.— Wherever  a  number  of 
men  are  together,  whether  in  a  camp  or  a  hospital,  or 
in  any  collection  of  persons,  the  danger  which  is  dreaded 
more  than  anything  else  is  the  outbreak  of  one  of  these 
infective  diseases.  If  it  starts  with  a  single  case,  unless 
prompt  measures  are  taken  to  head  it  off,  the  result  will 
be  that  everyone  susceptible  to  the  disease  in  the  hos- 
pital or  camp  will  be  infected.  Usually  the  only  way  to 
stamp  out  the  disease  is  to  close  down  temporarily  that 
camp  or  hospital.  Moreover,  if  these  diseases  develop 
on  a  surgical  wound  or  in  a  surgical  patient,  they  are  a 
great  deal  more  dangerous.    Sepsis  very  frequently  de- 

376 


MOUTH  AND  THROAT  SYMPTOMS    377 

velops  in  an  operative  wound.  One  of  the  common,  in- 
fective diseases  may  develop  which  is  the  reason  for 
mentioning  these  differ  en  t  troubles. 


THE    MOUTH    AND    THROAT    SYMPTOMS    OF   THE 
MORE    COMMON    DISEASES 

Measles 

Incidence. — First,  the  disease  known  as  measles  will  be 
considered.  Many  people  think  that  measles  are  con- 
fined to  children,  but  a  great  many  adults  are  suscepti- 
ble to  and  develop  measles.  A  short  time  ago  in  Bos- 
ton an  office  was  practically  closed  because  most  of  the 
stenographers  and  office  help  were  at  home  trying 
to  recover  from  the  measles.  Unless  a  person  has 
had  measles  in  childhood,  he  is  very  apt  to  develop 
it  in  adult  life  on  the  first  exposure,  and  when  a  collec- 
tion of  men  is  gathered  from  all  parts  of  the  world,  many 
of  them  coining  from  small  towns  and  rural  districts 
where  measles  has  not  been  incident,  it  is  surprising  to 
find  how  many  of  those  men  or  persons  will  develop 
measles  upon  exposure. 

Race  Susceptibility.— Another  point  is  that  if  measles 
is  developed  by  a  race  of  people  who  have  not  been 
subjected  to  it  over  a  number  of  years,  it  is  a  very 
severe  disease  and  often  fatal.  As  an  illustration  of 
that  fact:  some  years  ago  the  Fiji  Islanders  who  had 
never  been  exposed  to  measles  were  infected  in  some  way 
or  other,  through  a  visitor  or  some  member  of  a  ship's 
crew,  who  went  ashore,  and  the  measles  was  spread.  It 
went  like  wildfire  through  the  island,  and  the  mortality 
among  those  people  was  something  like  thirty  or  thirty- 
five  per  cent.  Most  of  the  northern  races  among  whom 
measles  is  endemic,  are  developing  a  certain  immunity 
day  by  day,  so  that  their  offspring  are  not  affected  so 
severely.     However,  this  disease  is  worth  serious  con- 


378    APPEARANCE  OF  MOUTH  IN  DISEASES 

sideration,  because  at  the  front  now  races  are  coming 
from  all  parts  of  the  world,  and  some  of  them  have  never 
been  subjected  to  measles. 

Measles,  known  also  as  rubeola  or  morbilli,  is  the  most 
contagious  of  any  of  the  infective  diseases.  One  attack 
usually  confers  immunity,  although  second  attacks  are 
not  uncommon.  The  cause  of  the  disease,  whether  bac- 
terial or  not,  is  not  known.  It  is  highly  contagious  even 
three  or  four  days  before  the  rash  or  eruption  appears. 
Only  a  very  short  exposure  is  necessary  in  order  to  con- 
tract the  disease.  The  incubation  period  is  from  eleven 
to  fourteen  days.  The  symptoms  of  the  disease  begin 
three  or  four  days  before  the  eruption  appears  on  the 
skin.  The  infection  is  probably  spread  by  the  secretions 
from  the  mucous  membranes  of  the  nose  and  throat.  It 
is  most  commonly  spread  by  means  of  the  cough,  which 
is  always  present. 

Symptoms.— The  classical  symptoms  are  as  follows: 
for  three  or  four  days  preceding  the  eruption,  there  is 
a  great  deal  of  inflammation  of  the  conjunctivae,  and  the 
mucous  membrane  of  the  nose,  throat  and  bronchii.  Ex- 
amination of  the  mouth  shows  a  congestion  of  the  ton- 
sils extending  on  to  the  soft  palate  and  pharynx.  On 
the  hard  palate  there  are  usually  a  few  red  spots  about 
the  size  of  a  split  pea.  These  spots  represent  the  first 
evidence  of  the  eruption,  appearing  first  in  this  place. 
The  sign  of  the  greatest  importance  diagnostically  is 
knowm  as  Koplik's  sign,  or  Koplik's  spots.  These  are 
small,  bluish-white  spots,  about  the  size  of  the  head 
of  a  pin,  each  one  being  surrounded  by  a  reddened  zone. 
They  are  exactly  the  same  in  adults  and  children.  They 
first  appear  on  the  mucous  membrane  of  the  cheek  op- 
posite the  molar  teeth.  They  may  spread  to  other  parts 
of  the  mouth  or  be  confined  to  the  original  areas.  Their 
number  varies.  There  may  be  only  a  few,  or  a  large  num- 
ber may  be  present.  There  is  always  cough  present  and 
a  good  deal  of  discharge  from  the  nose.     The  eyes  are 


MOUTH  AND  THROAT  SYMPTOMS    379 

swollen,  or  rather  the  eyelids,  with  an  increased  produc- 
tion of  tears.  These  symptoms  continue  for  about  three 
days,  after  which  the  rash  appears  on  the  skin. 

Infective  Stage.- — The  rash  begins  on  the  face,  then 
spreads,  covering  the  whole  body. 

It  can  easily  be  seen  that  the  most  important  factor 
is  to  recognize  measles  early  before  the  eruption  appears 
on  the  skin.  If  a  patient  with  measles  is  allowed  to  re- 
main in  contact  with  other  people  until  the  rash  appears 
one  might  just  as  well  let  him  stay  there  the  rest  of  the 
course,  because  he  has  done  all  the  damage  and  infected 
everyone  who  can  be  infected.  Of  course,  the  patient  is 
removed  at  that  time,  but  there  is  very  little  value  in  do- 
ing it,  because  the  infection  begins  as  soon  as  the  catar- 
rhal symptoms  develop ;  the  throat  and  nose  get  red,  the 
nose  beginning  to  run  and  the  eyelids  beginning  to  swell ; 
and  the  cough  appears.  From  that  point  on,  the  person  is 
infectious  to  others,  so  the  value  of  knowing  these  signs 
is  to  enable  us  to  get  the  suspects  isolated  before  they 
have  done  any  more  damage  than  is  possible,  and  to  pro- 
tect all  the  people  possible  from  further  infection. 

To  summarize :  Anyone  who  has  a  cough  should  be  an 
object  of  suspicion.  If  that  person,  in  addition  to  hav- 
ing a  cough,  develops  redness  of  the  eyelids,  a  running 
nose,  and  a  red  throat,  he  is  doubly  suspicious.  If,  in 
addition  to  these  signs,  Koplik's  spots  are  found  on  the 
mucous  membrane  of  the  mouth,  it  is  absolutely  certain 
that  the  case  is  one  of  measles  and  nothing  else,  because 
these  Koplik's  spots  do  not  occur  in  any  other  condition. 
Koplik's  spots  present  various  definite  characteristics 
in  various  stages  of  the  disease.  In  an  early  stage  of 
measles,  two  or  three  days  before  the  rash  or  eruption 
appears  on  the  skin,  they  appear  on  the  inside  of  the 
mouth  as  small,  discrete  red  spots,  the  center  of  each 
having  small,  bluish- white  specks. 

The  spots  become  more  numerous  and  coalesce  to  a 
certain  extent.     Then,  that  appearance  on  the  mucous 


380    APPEARANCE  OF  MOUTH  IN  DISEASES 

membrane,  speckled  all  over  with  the  small  white  spots 
becomes  evident.  If  there  are  very  many  of  them,  the 
inside  of  the  mouth  looks  very  much  as  though  the  person 
had  been  drinking  milk  and  some  of  the  curdled  milk  had 
adhered  to  the  mucous  membrane. 

In  a  still  later  stage  the  spots  become  larger,  coalesce 
more,  and  the  mucous  membrane  appears  studded  with 
these  numerous  small  white  specks.  That  appearance  is 
absolutely  characteristic  of  measles  and  nothing  else.  If 
it  is  seen  in  a  person's  mouth,  plus  the  catarrhal  symp- 
toms, one  can  say  absolutely  that  he  has  measles  and  no 
other  condition.  Once  in  a  while  there  is  one  symptom 
that  somewhat  resembles  this  Koplik's,  that  is  the  so- 
called  canker  spots  or  stomatitis.  These  spots,  however, 
are  very  much  larger,  are  ulcerated,  they  do  not  run  to- 
gether and  they  are  very  much  fewer  in  number.  They 
are  the  only  things  that  can  possibly  be  confused  with  the 
Koplik's  spots. 

One  more  point  to  remember  is  that  the  Koplik's  spot 
begins  with  a  few  spots  and  increases  in  number,  finally 
coalescing  in  the  speckled,  whitish  appearance.  The 
stomatitis,  or  canker  spots,  on  the  contrary,  always 
remain  discrete.  They  do  not  coalesce,  are  much  less  in 
number,  and  the  individual  spots  are  larger  than  the  in- 
dividual Koplik's. 

Essential  Points.— To  reiterate  briefly:  the  points  to 
remember  about  measles  are  that  the  disease  is  highly  in- 
fectious long  before  the  eruption  comes  out,  and  that  in 
order  to  prevent  infection  for  other  people,  the  patient 
having  the  disease  must  be  removed  before  the  rash  ap- 
pears. Any  person  under  one's  care  developing  a  cough 
should  be  suspected  of  having  measles  until  he  can  prove 
to  the  contrary.  If  that  patient  has  a  cough  and  also  de- 
velops swollen  eyelids  and  running  nose,  then  the  chances 
of  his  having  measles  are  very  great  and  he  should  be  iso- 
lated until  it  is  proven  definitely  whether  or  not  he  has  the 
disease.    If,  in  addition  to  the  cough,  the  running  nose, 


MOUTH  AND  THROAT  SYMPTOMS    381 

and  the  swollen  eyelids,  the  Koplik's  spots  appear  in  the 
mouth,  it  is  absolutely  sure  that  that  patient  will  show 
the  eruption  of  measles  within  three  or  four  days. 

German  Measles.— Another  point  should  be  mentioned 
in  connection  with  this  subject,  and  that  is,  "What  does 
one  mean  by  German  measles?  Is  German  measles  the 
same  as  ordinary  measles,  or  is  it  different?"  German 
measles  is  a  distinct  disease  and  has  no  relation  to  ordi- 
nary measles.  It  is  very  mild  in  its  course.  It  has  few 
or  no  prodromal  symptoms.  Usually  the  first  sign  is 
the  appearance  of  the  rash.  There  is  no  swelling  of  the 
eyelids.  There  is  little  or  no  cough  and  very  little,  if 
any,  nasal  discharge.  The  rash  differs  in  appearance 
and  in  intensity.  It  lasts  two  or  three  days  and  disap- 
pears. The  importance  of  this  disease  lies  not  in  the 
treatment  but  in  the  recognition  of  the  early  signs,  so 
that  patients  can  be  put  where  they  will  do  no  further 
damage. 

Scarlet  Fever 

The  next  in  order  of  common  infective  diseases  is  scar- 
let fever.  A  good  many  people  think  that  scarlatina  is  a 
mild  form  of  scarlet  fever.  The  fact  is  that  the  two  terms 
mean  exactly  the  same  thing,  scarlatina,  or  scarlet  fever; 
those  terms  are  used  synonymously.  It -is  an  acute,  con- 
tagious disease,  characterized  by  a  sore  throat,  fever,  and 
a  fine  red  eruption  on  the  skin.  The  incubation  period  is 
very  short,  varying  in  length  from  six  hours  to  one  week. 
The  disease  is  followed  by  desquamation,  which  requires 
from  four  to  seven  weeks  to  be  complete.  The  cause  of 
the  disease  is  probably  a  minute,  short-lived  microorgan- 
ism which  has  been  discovered  within  the  last  few  months. 

Symptoms.— The  symptoms  of  the  disease  are  as  fol- 
lows :  first  there  is  a  rise  in  temperature,  varying  from 
100  to  104  degrees.  At  the  same  time,  a  sore  throat  de- 
velops which  gradually  increases  in  severity;  in  about 
fifty  per  cent  of  the  cases,  vomiting  is  an  early  sign ;  and 


382    APPEARANCE  OF  MOUTH  IN  DISEASES 

in  from  T2  to  48  hours  after  the  appearance  of  the  sore 
throat,  the  rash  appears  on  the  skin.  This  rash  is  deep 
red  in  appearance,  not  raised,  and  begins  first  behind 
the  ears  or  upon  the  cheeks.  It  then  spreads,  covering 
more  or  less  of  the  whole  body.  Examination  of  the 
mouth  shows  the  following  symptoms :  the  tonsils  are 
swollen  and  much  reddened,  and  in  the  majority  of  cases 
there  is  a  varying-  amount  of  tonsillar  exudate.  This 
exudate  may  appear  as  small  spots  resembling  tonsillitis, 
or  it  may  be  in  the  form  of  a  patch,  partly  or  wholly 
covering  the  organ.  The  pharynx  and  soft  palate  are 
intensely  red.  On  the  hard  palate  there  is  a  large  num- 
ber of  very  fine,  red  spots,  and  this  is  the  first  appear- 
ance of  the  rash  on  the  hard  palate.  Early  in  the  disease 
the  tongue  is  coated,  the  edges  and  tip  are  reddened, 
with  a  marked  enlargement  of  the  papillae  of  the  tongue. 
Within  two  or  three  days  the  tongue  desquamates,  and 
is  then  smooth,  deep  red  in  color,  with  a  marked  enlarge- 
ment of  the  papillae.  This  forms  what  is  known  as  the 
strawberry  tongue  of  scarlet  fever. 

The  essential  points  regarding  scarlet  fever  should 
be  emphasized.  Anyone  who  has  a  sore  throat  is  suspi- 
cious, and  should  be  watched.  If,  in  addition  to  the  sore 
throat,  the  patient  vomits,  he  is  doubly  suspicious.  If 
on  examination  the  throat  is  found  to  have  a  marked 
congestion  of  the  tonsils,  pharynx,  and  soft  palate,  and 
shows  a  large  number  of  very  small,  fine  red  dots  on 
the  hard  palate,  the  chances  are  that  that  patient  is  go- 
ing to  have  scarlet  fever.  In  cases  of  this  disease,  as 
with  the  rest  of  the  infective  diseases,  the  earlier  they 
are  removed  from  contact  with  other  people,  the  less 
the  danger  of  contagion.  The  old-time  idea  was  that  a 
person  with  scarlet  fever  was  not  very  dangerous  un- 
til he  commenced  to  "peel,"  as  it  is  called.  Then  the 
patient  was  anointed  with  different  kinds  of  greases  and 
lotions  to  keep  the  dead  skin  from  flying  around  and 
infecting  other  people.    It  has  been  found,  within  a  com- 


MOUTH  AND  THROAT  SYMPTOMS    383 

paratively  recent  time,  that  this  dead  skin  is  very  little, 
if  at  all,  infectious;  that  the  infection  is  not  in  the  dead 
skin,  but  comes  early  in  the  disease,  and  is  contained  in 
the  discharge  from  the  nose  or  mouth  of  the  patient. 
The  time  when  he  is  most  contagious  is  during  the  early 
stages  when  the  throat  is  red  and  the  rash  is  on  the 
skin.  It  is  relatively  safe  to  go  where  a  patient  is  des- 
quamating. There  is  very  little  danger  from  the  des- 
quamating skin — so  much  so  that  within  the  last  year 
or  so  in  Boston,  the  authorities  do  not  even  fumigate  after 
scarlet  fever.  As  soon  as  patients  have  done  peeling, 
they  are  discharged,  and  the  room  is  merely  aired,  sub- 
jected to  sunlight  and  a  good  application  of  soap  and 
water.  The  point  to  remember  then,  is  that  the  desqua- 
mating skin  is  not  so  infectious  as  formerly  considered, 
but  that  the  danger  comes  early  in  the  disease  when  the 
throat  is  sore  and  from  the  discharge  from  the  throat 
and  nose. 

Infectious  Discharges. — Another  point  that  is  not  gen- 
erally known  is  that  there  is  a  great  deal  of  liability  to 
complications  in  this  disease;  a  good  many  children  de- 
velop abscess  of  the  ear,  and  have  a  running  ear  for 
a  variable  length  of  time.  Others,  who  are  troubled  with 
an  enlargement  of  the  adenoid  growth,  develop  a  chronic 
inflammation  of  the  adenoids,  which  results  in  more  or 
less  of  a  chronic  discharge  from  the  nose.  So  that  as 
a  complication  of  scarlet  fever  there  may  be  running 
ears  and  running  nose;  and  as  long  as  any  patient  having 
had  scarlet  fever  has  a  running  nose  or  a  running  ear,  he 
is  in  a  condition  to  spread  the  disease.  At  the  hospital 
for  contagious  diseases  in  Boston  children  were  kept 
sometimes  ten  or  twelve  weeks,  sometimes  three  months, 
until  it  was  thought  that  the  ears  were  clear,  adenoids 
quieted  down,  and  that  there  was  no  discharge  from  the 
nose,  etc.  The  patient  would  be  sent  home,  might  develop 
a  little  cold,  and  for  some  reason  or  other  the  ear  or  nose 
would  start  to  run  again.    Inside  of  a  week  or  ten  days 


:iS4    APPKARANCE  OF  MOUTH  IN  DISEASES 

there  might  be  anywhere  from  one  to  two  or  three  more 
children  in  the  hospital,  from  that  same  family.  So  it 
must  be  remembered  that  so  long  as  a  scarlet  fever  pa- 
tient has  a  running  nose,  or  a  running  ear,  the  discharges 
from  those  parts  of  the  body  are  contagious,  and  are 
capable  of  spreading  the  disease. 

Ambulant  Cases.— Before  concluding  a  discussion  of 
scarlet  fever  mention  must  be  made  of  the  much  dis- 
puted question  as  to  whether  or  not  scarlet  fever  can 
occur  without  the  appearance  of  any  eruption  or  rash 
upon  the  body.  There  is  a  good  deal  of  difference  of 
opinion  as  to  whether  one  can  have  scarlet  fever  without 
having  any  eruption.  The  question  is  not  yet  definitely 
settled,  but  the  probabilities  are  that  this  is  possible.  The 
ordinary  idea  of  a  patient  with  scarlet  fever  is  of  some- 
one desperately  ill.  Xow,  some  people  certainly  are,  but 
it  seems  safe  to  say  that  many  persons  with  scarlet  fever 
are  not  very  sick,  and  there  are  a  great  number  of  scarlet 
fever  patients  who  are  never  sick  enough  to  go  to  bed. 
They  are  up  and  around  and  attend  school  regularly, 
and  those  are  the  ones  that  spread  the  disease.  A  pa- 
tient who  is  known  to  have  a  very  mild  case  of  scarlet 
fever  can  infect  another  person,  who  may  in  turn  develop 
one  of  the  most  virulent  cases  of  the  disease.  Many 
cases  of  scarlet  fever  have  been  seen  where  the  rash  only 
lasted  two  or  three  hours  and  was  confined  to  a  small 
part  of  the  body,  possibly  the  axillae  or  the  groin ;  it  ap- 
peared as  a  small  patch  of  rash  possibly  six  or  eight 
inches  in  circumference.  By  the  next  morning  that  rash 
would  have  practically  disappeared.  The  only  thing  the 
patient  would  complain  of  was  a  little  sore  throat.  Now 
those  cases  are  scarlet  fever  just  as  much  as  the  most  vi- 
rulent case,  where  the  rash  is  so  intense  that  it  can  be  seen 
across  the  room.  Consequently,  if  a  case  of  scarlet  fever 
breaks  out  in  a  ward,  special  precaution  should  be  taken 
against  these  so-called  ' '  m  ild ' '  cases.  If  scarlet  fever  has 
appeared  in  a  ward  or  in  a  hospital  or  in  a  camp,  every 


MOUTH  AND  THROAT  SYMPTOMS    385 

person  should  be  isolated  who  develops  a  sore  throat,  ir- 
respective of  the  fact  that  he  have  a  rash  or  not,  because 
many  of  them  may  have  had  mild  rashes  that  could  not 
be  seen,  or  that  disappeared  before  examination  was 
made.  If  this  is  done,  the  epidemic  will  probably  be 
nipped  in  the  bud. 

Diphtheria 

Before  considering  the  subject  of  diphtheria  a  word 
should  be  said  about  sore  throats  in  general.  There  is 
no  person  who  can  positively  diagnose  diphtheria  or  who 
can  state  definitely  from  the  appearance  of  a  throat  that 
a  certain  case  is  diphtheria,  a  certain  case  tonsillitis,  or 
a  certain  case  some  other  throat  infection.  A  culture 
should  be  taken  on  every  case  of  sore  throat  that  occurs, 
especially  in  hospital  practice  or  where  there  are  a  large 
number  of  men  congregated  under  one  roof.  This  is  the 
only  way  of  proving  the  presence  or  absence  of  diph- 
theria. In  the  majority  of  cases  it  is  easy  to  diagnose, 
but  the  absolutely  safest  way  is  to  take  a  culture. 

Klebs-Loeffler  Bacillus.— Diphtheria  is  an  acute,  com- 
municable disease,  due  to  a  specific  organism  which  is 
known  as  the  Klebs-Loeffler  bacillus,  Klebs  being  the 
name  of  one  man  and  Loeffler  the  name  of  another,  who 
discovered  this  organism  independently,  one  a  year 
after  the  other.  This  disease  is  usually  characterized  by 
the  formation  of  a  false  membrane  on  certain  mucous 
membranes,  especially  those  of  the  tonsil,  nose,  pharynx 
and  larynx.  Those  are  the  four  important  points  in- 
volved in  diphtheria. 

The  average  person,  when  speaking  of  diphtheria,  im- 
agines a  sore  throat,  but  the  diphtheria  organism  may 
grow  on  any  mucous  membrane,  the  conjunctiva,  for 
instance.  The  bacillus  can  occur  on  any  open  or  granu- 
lating wound,  and  the  patient  will  be  extremely  sick  and 
very  likely  die,  when  diphtheria  of  this  kind  occurs.  It 
is  not  unusual.    Cases  have  been  known  where  a  person 


386    APPEARANCE  OF  MOUTH   IX  DISEASES 

was  burned  and  developed  diphtheria  on  the  wound. 
Therefore,  although  diphtheria  is  usually  confined  to  the 
throat,  it  may  occur  on  any  mucous  membrane  or  may 
occur  on  any  wound. 

In  the  great  majority  of  cases  diphtheria  is  spread  by 
direct  infection,  that  is,  by  contact  with  the  patient.  The 
breath  of  the  patient  probably  does  not  contain  the  or- 
ganisms. The  bacilli  are  present  in  great  numbers  in  the 
saliva  and  the  mucous  discharge  from  the  nose.  They 
are  rather  long-lived  organisms.  They  have  been  found 
virulent  on  a  child's  toy  five  months  after  the  toy  was 
infected.  Milk  is  a  very  common  mode  of  spreading  the 
disease.  It  rarely  spreads  through  the  water  supply. 
Persons  with  enlarged  tonsils,  adenoids  or  a  chronic 
inflammation  of  the  throat  are  much  more  susceptible  to 
this  disease  than  others.  The  incubation  period  is  from 
two  to  five  days.  One  attack  does  not  confer  immunity, 
as  a  second  attack  has  occurred  in  some  cases  within  two 
months  after  recovery  from  the  first. 

Symptoms.— The  symptoms  of  the  disease  are,  first, 
elevation  of  the  temperature  or  fever,  a  certain  amount 
of  malaise  or  discomfort,  and  sore  throat.  In  the  major- 
ity of  cases  the  tonsil  is  the  point  affected;  the  nose  is 
frequently  involved,  either  alone  or  as  a  part  of  a  ton- 
sillar attack.  Examination  of  the  throat  shows  the  ton- 
sils swollen  and  red.  The  tissues  immediately  surround- 
ing the  tonsils  are  also  reddened.  On  the  tonsil  a  vary- 
ing amount  of  membrane  is  seen.  In  the  mild  cases  only 
a  very  small  amount  may  be  present.  One  tonsil  may  be 
affected  or  both.  This  membrane  usually  begins  as  a 
small  spot  and  gradually  increases.  Except  in  severe 
cases,  it  is  wholly  confined  to  the  tonsils.  In  severe  cases 
it  spreads  and  involves  the  uvula  and  the  soft  palate.  The 
membrane  is  of  a  grayish  white  color,  gradually  becom- 
ing darker.  It  is  rather  thick  and  has  a  well  defined  edge. 
It  is  difficult  to  remove  from  the  tonsil,  and  when  re- 
moved it  leaves  a  raw,  bleeding  surface.     The  tempera- 


MOUTH  AND  THROAT  SYMPTOMS    387 

ture  in  diphtheria  is  only  slightly  elevated;  100  degrees 
to  102  degrees  is  the  average.  If  there  is  a  mixed  infec- 
tion, the  temperature  is  apt  to  be  very  high,  103,  104,  or 
even  105  degrees.  The  point  to  be  emphasized  is  that  if 
a  patient  has  a  sore  throat  and  any  spots  of  exudate  on 
the  tonsil  with  an  accompanying  temperature  of  104 
to  105  degrees,  it  is  more  apt  to  be  tonsillitis  than  it  is 
to  be  diphtheria.  The  pure  infection  of  diphtheria  has 
usually  a  low  temperature,  101  to  102  degrees. 

With  the  sore  throat  and  temperature  there  is  always 
involvement  of  the  glands  of  the  neck.  The  appearance 
of  the  throat  is  rather  characteristic.  In  most  cases  the 
membrane  is  either  confined  to  or  beginning  on  the  ton- 
sil and  in  severe  cases  it  spreads  to  the  other  parts. 

Nasal  Diphtheria. — One  form  of  diphtheria  that  is  very 
largely  overlooked  is  diphtheria  of  the  nose  or  nasal 
diphtheria.  It  is  a  very  common  condition,  especially 
in  children,  although  adults  may  have  it.  It  often  occurs 
limited  to  the  nose,  the  throat  not  being  involved.  It  is 
often  chronic  in  its  course,  continuing  a  number  of  weeks. 
During  this  time  the  person  is  not  confined  to  the  bed; 
he  is  up  and  around  and  feels  moderately  well.  The 
signs  of  this  disease  are,  first,  a  little  interference  with 
the  nasal  breathing  due  to  the  swelling  in  the  nose.  There 
is  a  persistent  nasal  discharge,  which  is  only  slightly 
purulent.  Occasionally  this  is  blood  tinged.  There  is  al- 
most always  more  or  less  excoriation  of  the  external 
nares.  These  nasal  cases  are  the  cause  of  a  large  percent- 
age of  the  diphtheria  which  occurs.  The  patient  feels 
pretty  well,  except  for  the  persistent  nasal  discharge. 
This  is  not  thick  but  more  or  less  thin,  serous  and  usually 
blood  tinged.  The  external  nares  are  almost  always  raw 
and  sore  from  this  exudate.  The  culture  is  the  only  way 
to  make  a  diagnosis.  The  patient  should  be  subjected  to 
cultures  from  the  nasal  discharge,  and  in  the  majority  of 
cases  it  will  prove  positive.  Children  or  adults  having 
this  condition  spread  the  infection  by  mingling  with  oth- 


388    APPEARANCE  OF  MOUTH  IN  DISEASES 

ers,  but  do  not  necessarily  spread  nasal  diphtheria.  One 
of  the  most  virulent  types  of  diphtheria  may  be  engen- 
dered. In  the  nose  some  of  the  organisms  seem  to  be  of 
low  grade  virulence,  but  start  to  grow  strongly  on  fresh 
soil.     That  is  a  very  important  point  to  remember. 

Diphtheritic  Croup.  — One  condition  which  does  not 
often  occur,  but  which  can  be  mentioned  in  passing,  is 
the  presence  of  the  diphtheritic  membrane  in  the  larynx. 
It  is  not  very  common  in  adults,  but  it  does  happen  every 
once  in  a  while.  It  usually  occurs  as  a  result  of  failure 
to  treat,  or  failure  to  recognize,  a  case  of  diphtheria  either 
tonsillar  or  nasal.  The  symptoms  of  this  are  interfer- 
ence with  the  breathing.  This  disease  is  frequently  seen 
when  it  is  primary  in  the  larynx  and  there  is  nothing  in 
the  throat  or  the  nose.  In  those  cases  it  is  very  difficult 
to  make  a  diagnosis.  The  chief  symptom  is  that  the  pa- 
tient has  the  croup.  Usually  there  is  very  little  tempera- 
ture, oftentimes  not  more  than  100  degrees;  sometimes 
not  as  much  as  that ;  but  the  croup,  instead  of  acting  as 
the  croup  usually  does,  gradually  gets  worse,  so  that  any 
person  who  has  been  exposed  to  diphtheria  who  develops 
the  croup,  that  is,  interference  with  breathing,  with  the 
symptoms  gradually  increasing  in  severity  for  twenty- 
four  hours,  usually  is  a  case  of  diphtheritic  croup.  Cul- 
tures from  these  cases  are  often  perfectly  negative  simply 
because  the  culture  rod  cannot  be  introduced  deeply 
enough.  A  case  of  that  kind  should  be  given  antitoxin 
and  the  antitoxin  will  help  to  clear  up  the  diagnosis  by 
relieving  the  symptoms. 

Vincent's  Angina 

A  few  words  should  be  said  here  about  a  disease  which 
is  frequently  seen.  It  is  the  condition  known  as  Vin- 
cent's angina.  This  is  an  infection  of  the  throat  and 
other  parts  of  the  mouth,  caused  by  the  combined  ef- 
fect of  a  spindle-shaped  bacillus  and  a  spirochete.    Those 


MOUTH  AND  THROAT  SYMPTOMS    389 

two  organisms  work  together,  causing  this  disease.  It 
is  seen  in  adults  rather  than  in  children.  It  usually  af- 
fects the  tonsils,  where  it  may  remain  or  it  may  spread 
to  other  parts  of  the  throat  and  mouth.  Often  only  one 
tonsil  is  affected.  The  symptoms  are  fever,  sore  throat, 
enlarged  glands  in  the  neck,  and  constitutional  disturb- 
ance, depending  upon  the  severity  of  the  infection.  This 
condition  is  characterized  by  the  formation  of  ulcers, 
which  become  covered  with  a  membrane.  The  tonsils  and 
surrounding  tissues  are  red  and  swollen.  The  ulcers 
vary  in  number,  in  size  and  in  depth.  They  are  covered 
with  a  thick,  dark-colored,  sometimes  almost  black,  mem- 
brane. This  membrane  is  difficult  to  remove.  When 
taken  out,  it  leaves  a  deep,  bleeding  ulcerated  surface. 
On  removal  it  re-forms  within  a  few  hours.  The  interest- 
ing feature  of  this  disease  is  its  resemblance  to  diph- 
theria. Sometimes  it  is  impossible  to  differentiate  the 
two.  Differentiation  can  usually  be  made,  however,  by 
the  fact  that  the  membrane  is  much  darker  in  color, 
sometimes  almost  black.  Then  there  is  the  presence  of 
ulcers,  which  are  not  present  in  diphtheria.  Diphtheria 
does  not  ulcerate,  and  Vincent's  angina  does.  Dentists 
are  probably  better  acquainted  with  these  cases  than 
medical  men.  Some  of  the  cases  of  inflammation  of  the 
gums  (gingivitis)  seen  by  dentists  are  probably  due  to 
Vincent's  angina  organisms.  The  reason  for  mentioning 
it  here  is  that  it  may  attack  the  throat  and  may  be  con- 
founded with  diphtheria.  These  two  diseases  oftentimes 
occur  together,  but  the  Vincent 's  angina  organisms  cover 
up  the  diphtheria  organisms,  so  the  latter  cannot  be  found 
until  one  gets  rid  of  the  Vincent's  angina.  If  there  is  any 
suspicion  of  diphtheria,  antitoxin  should  be  given,  and 
probably  in  three  or  four  days  later  the  culture  of  the 
diphtheria  organism  can  be  obtained. 

O'Dwyer  Tube.— The  illustration  shows  an  interesting 
apparatus.  In  diphtheritic  croup  the  symptoms  some- 
times progress  so  far  that  it  is  impossible  for  the  patient 


390    APPEARANCE  OF  MOUTH  IN  DISEASES 

to  breathe.  In  the  olden  times  the  only  method  was  to  do 
tracheotomy,  and  such  operations  were  usually  fatal. 
Out  of  twenty-six  tracheotomies  for  laryngeal  diphtheria 
the  writer  had  a  mortality  of  twenty-four.  That  is  about 
the   average  mortality  for   tracheotomy  for  laryngeal 


Fig.  171. — O'Dwyer's  Intubation  Tubes.     (From  Shurley.) 


diphtheria.  That  being  the  case,  a  method  was  devised 
for  allowing  these  patients  to  breathe.  This  is  done  by 
what  is  known  as  the  O'Dwyer  Intubation  Tubes.  These 
tubes  are  graduated  in  size  and  inserted  into  the  larynx. 
The  one  shown  would  be  for  a  child  ten  or  twelve  years 
of  age.  It  is  inserted  through  the  mouth.  Each  one  has 
an  obturator  and  is  screwed  into  the  instrument.     The 


MOUTH  AND  THROAT  SYMPTOMS    391 

tube  is  put  on  to  the  apparatus  and  held  in  the  right  hand. 
The  forefinger  of  the  left  hand  is  put  back  into  the  larynx, 
into  which  the  tube  is  passed.  When  the  tube  is  well  into 
the  larynx,  a  little  button  is  pushed,  which  releases  the 
obturator.  This  is  then  drawn  out,  leaving  the  tube  in 
the  larynx.  It  is  of  hard  rubber,  metal-lined,  and  the  pa- 
tient breathes  through  the  tube.  Out  of  three  hundred 
cases  there  was  a  mortality  of  about  twenty  per  cent, 
which,  when  contrasted  with  a  mortality  of  practically 
ninety-eight  per  cent  in  tracheotomy,  shows  a  marked  dif- 
ference. These  tubes  come  in  all  sizes,  down  to  a  tube 
suitable  for  a  child  one  year  of  age.  This  is  really  one 
of  the  greatest  life-saving  inventions  of  recent  times. 
It  has  been  out  now  a  number  of  years  and  probably  most 
practitioners  have  heard  of  it. 

It  may  be  said  that  in  families  where  there  is  diph- 
theria the  rule  is  to  inject  all  persons  who  have  been 
exposed  to  the  disease  with  a  small  dose  of  the  antitoxin. 
This  procedure,  however,  gives  immunity  for  two  or  three 
months  only. 


CHAPTER  XV 

RECENT  ADVANCES  IN  DENTAL  SURGERY  AND  TECHNIC 

Harry  B.  Shuman,  D.M.D. 

Under  the  subject  of  recent  advances  in  dental  sur- 
gery and  technic  some  attention  will  be  given  to  elec- 
tricity, in  other  words,  ionization,  as  it  is  viewed  in  den- 
tistry. 

ELEMENTS  OF  ELECTROLYSIS 

A  few  A  B  C's  of  electrolysis,  which  covers  the  whole 
field  of  what  is  called  galvanism  or  direct  currents,  will 
be  first  reviewed.  In  order  to  get  a  comprehensive  idea 
of  this  subject  one  must  consider  for  a  moment  its  rudi- 
ments. It  is  necessary  to  know  something  about  voltage, 
amperage  and  resistance;  and  a  few  moments  spent  in 
studying  those  three  elementals  are  well  worth  while. 

Voltage.— Voltage  is  not  electricity  but  only  one  of  the 
component  parts  of  electrical  energy,  and  though  it  is 
itself  perfectly  harmless  it  becomes  a  dangerous  factor 
under  certain  conditions.  Voltage  is  the  pressure  at 
which  electricity  is  used,  and  can  be  likened  to  the  pres- 
sure in  the  steam  boiler.  One  would  not  call  the  pres- 
sure in  the  boiler  steam,  and  it  would  be  evidently  as 
improper  to  call  voltage  electricity.  It  is  pressure;  in 
other  words,  it  is  electromotive  force,  and  the  abbrevia- 
tion E.  M.  F.  is  the  one  constant  abbreviation  for  electro- 
motive force  in  any  of  the  books  discussing  this  subject. 
It  always  means  Voltage. 

Amperage. — In  most  text-books  the  word  amperage  is 

392 


ELEMENTS  OF  ELECTROLYSIS  393 

defined  as  amount  or  quantity.  This  is  wrong,  because 
one  must  not  look  on  electricity  as  an  entity  but  a  con- 
dition. Amperage  is  only  the  rate  at  which  electricity 
flows,  and  that  rate  is  governed  entirely  by  the  pressure 
or  voltage.  If  a  dentist  says,  "I  am  giving  a  patient  50 
milli-amperes  of  current,"  he  means  that  the  rate  of 
flow  of  50  milli-amperes  is  maintained  throughout  the 
entire  circuit,  and  consequently  just  that  much  electricity 
is  passing  through  the  patient. 

Resistance. — The  third  element  in  electrolysis  is  re- 
sistance. This  means  anything  that  opposes  the  passage 
of  electricity.  Every  force  has  its  resistance ;  if  this  were 
not  so  one  would  be  able  to  make  something  out  of  noth- 
ing, or  be  able  to  produce  perpetual  motion. 

It  is  necessary  to  understand  that  there  is  a  definite 
relationship  existing  between  the  factors  voltage,  am- 
perage and  resistance,  and  that  it  is  impossible  to  de- 
stroy this  relationship.  If  two  electrodes  of  an  active 
galvanic  battery  be  placed  on  the  body,  and  a  certain 
amount  of  pressure  or  voltage  be  turned  into  the  circuit, 
a  definite  rate  of  flow  or  amperage  will  be  established.  If 
these  electrodes  are  moved  to  another  part  of  the  body, 
or  the  distance  increased  between  these  two  electrodes, 
the  same  amount  of  voltage  will  not  maintain  the  same 
current  flow. 

That,  briefly,  is  the  essence  of  the  whole  subject.  In 
other  words,  by  separating  the  two  acting  electrodes 
resistance  is  increased  to  the  current  between  the  two 
poles,  and  in  order  to  maintain  original  amperage  or 
flow  of  current,  one  must  either  increase  the  pressure 
or  decrease  the  resistance.  In  other  words,  what  is 
gained  in  one  of  these  factors  must  be  at  the  expense  of 
the  other.  It  is  very  easy  to  change  force  or  energy  from 
one  form  to  another,  and  this  interchange  of  energy  is 
the  physical  life  of  this  world.  The  chemical  energy 
within  a  cell  begets  electrical  energy  and  with  this  one 
can  in  turn  break  up  a  chemical  compound.    So  a  simple 


394         ADVANCES  IN  DENTAL  SURGERY 

definition  of  electrolysis  is  the  breaking  up  by  electricity 

of  substances  into  their  elements. 


Direction  of  Ions 

In  studying  this  subject  the  main  fact  to  be  kept  in 
mind  is  that  there  are  certain  products  of  decomposition 
which  were  named  by  Faraday  "ions."  These  ions  take 
a  definite  direction  toward  one  or  the  other  pole  of  the 
battery.  Some  have  strong  affinity  for  the  positive  pole, 
and  others  for  the  negative.  Those  ions  appearing  at  the 
positive  pole  are  called  electronegative  substances;  like- 
wise those  appearing  at  the  negative  side  are  called  elec- 
tropositive. 

The  body  fluids  are  composed  largely  of  water,  and 
therefore  contain  oxygen  and  hydrogen.  In  the  process 
of  electrolysis  the  former  is  electronegative. 

Acidity  and  Alkalinity  at  the  Poles.— If  the  applica- 
tion of  one  pole  is  indicated  for  a  certain  condition  the 
other  will  aggravate  it,  so  it  becomes  necessary  to  be- 
come thoroughly  conversant  with  this  part  of  the  sub- 
ject. Oxygen  is  an  acid  maker;  consequently  tissues  ad- 
jacent to  the  positive  pole  are  rendered  acid.  The  acid 
condition  is  one  antagonistic  to  pain,  as  it  means  the 
beginning  of  death  of  the  tissue.  Consequently  this 
pole  is  called  sedative. 

Hydrogen  is  an  alkali  maker;  therefore  tissues  in  the 
immediate  vicinity  of  this  pole  are  rendered  alkaline, 
and  that  means  a  condition  of  overstimulation  or  irrita- 
tion. All  inflammations  are  due  to  an  excessive  alka- 
linity of  the  part. 

The  positive  pole  by  its  acidity  coagulates  the  albumen 
of  the  blood,  and  therefore  hardens  and  shrinks  tissue. 
The  negative  pole  acts  like  caustic  soda,  liquefying  or 
disintegrating  the  tissue. 


IONIZATION  395 


CATAPHORESIS 


Cataphoresis  is  the  process  of  introducing  medica- 
ments into  the  tissues  and  circulation  by  means  of  the 
direct  current.  That  is  a  definition  which  will  pass  mus- 
ter. Many  misleading  statements  have  appeared  in  the 
literature  regarding  this  process,  the  principal  one  of 
which  is  that  because  the  movement  of  a  direct  current 
is  from  the  positive  to  the  negative  pole  all  medicine 
must  be  placed  on  the  positive  pole  so  as  to  be  pushed 
along  in  the  direction  of  the  current.  Cataphoresis  is  an 
electrolytic  process  and  follows  closely  the  laws  of  elec- 
trolysis, and  whenever  suitable  medicine  is  placed  on 
either  pole  of  a  galvanic  battery,  that  medicine  is  decom- 
posed or  broken  up  into  its  elements  or  ions,  which,  hav- 
ing an  affinity  for  one  or  the  other  pole  of  the  battery,  the 
selection  of  the  active  pole  would  depend  on  what  part  of 
the  medicine  it  is  wished  to  use. 

The  medicament  is  carried  deeply  into  the  tissues,  the 
depth  depending  on  the  amperage  and  the  length  of  time 
the  current  is  allowed  to  flow.  It  is  not  hard  to  formu- 
late a  rule  to  govern  these  cataphoric  operations.  If 
it  is  kept  in  mind  that  all  bases,  whether  metallic  or 
alkaloidal,  have  an  affinity  for  the  negative  pole  and  are 
repelled  by  the  positive,  and  that  the  acid,  or  that  which 
takes  its  place,  has  just  as  strong  an  affinity  for  the 
positive  and  is  repelled  by  the  negative,  the  rule  would 
be  stated  as  follows — if  one  wants  to  utilize  the  base, 
medicine  is  placed  on  positive  pole;  if  acid  is  desired, 
the  negative  pole  is  used. 

IONIZATION 

Uses.— A  combination  of  the  two  subjects  briefly  dis- 
cussed above  is  what  is  termed  ionization  today.  It  has 
a  wonderful  field  in  the  practice  of  dentistry.    It  is  used 


396    ADVANCES  IN  DENTAL  SURGERY 

in  the  treatment  of  pyorrhea ;  for  sterilizing  the  root 
canal,  fistulous  tracts  and  old  sinuses;  for  cauterizing 
purposes;  for  desensitizing  dentin  and  for  pulp  removal; 
and  it  will  no  doubt  be  used  in  the  future  for  an  indefinite 
additional  number  of  things. 

In  Pyorrhea. — This  treatment  is  used  in  the  treatment 
of  Riggs'  Disease  or  pyorrhea.  Of  all  the  new  technics 
and  various  fads  relative  to  the  treatment  of  pyorrhea 
this  has  been  found  superior  to  any.  Either  three  per  cent 
chlorid  of  zinc  is  used  on  the  electrode,  or  a  two  per  cent 
sulphate  of  copper  solution. 

This  procedure  will  be  described  briefly.  After  the 
instrumentation  in  pyorrhea  where  there  are  very  deep 
pockets  and  the  degeneration  of  the  bone  is  marked,  even 
though  the  softer  tissues  have  not  yet  degenerated,  the 
electrode,  wrapped  with  cotton,  is  placed  in  the  pocket 
and  run  for  from  two  to  five  minutes.  This  is  the  most 
beneficial  local  therapeutic  agent  the  writer  knows  in  the 
treatment  of  pyorrhea.  A  few  applications  of  this  treat- 
ment stop  the  worst  possible  cases  of  bleeding  gums,  and 
a  few  more  additional  ones  will  stop  pus  where  it  can  be 
stopped.  If  the  treatment  with  zinc  ions  and  copper 
ions  does  not  stop  pus  flow,  it  is  doubtful  whether  any- 
thing will. 

In  treating  pyorrhea  after  thorough  instrumentation 
the  writer  usually  applies  this  treatment,  taking  three  or 
four  teeth  each  time,  depending  on  the  ease  of  manipu- 
lation. By  that  is  meant  that  the  technic  of  ionization 
is  extremely  difficult,  insomuch  as  it  requires  critical  at- 
tention to  detail.  In  other  words,  the  electrode  applied 
to  a  pocket  of  a  tooth  must  reach  that  pocket  and  not 
touch  another  thing  on  its  way.  If  it  touches  the  cloth- 
ing or  cheek  of  the  patient  it  is  a  failure.  The  patient 
is  usually  seen  three  days  a  week  for  two  or  three  weeks, 
and  then  once  a  week  on  the  least  reacting  pockets  in  the 
mouth.  More  has  been  accomplished  with  this  method 
than  with  any  other  technic  the  writer  knows  of. 


IONIZATION  397 

Other  treatments  of  the  disease,  including  the  intra- 
muscular and  intra-oral,  have  been  tried  conscientiously, 
and  have  been  relegated  to  the  scrap-heap. 

The  strength  of  current  to  be  used  is  in  proportion  to 
the  point  of  tolerance  or  sensation  by  the  patient.  It  is 
turned  on  slowly,  and  when  the  patient  says  he  feels  the 
current  it  is  allowed  to  run  there,  not  any  more,  and  the 
purpose  is  accomplished  thoroughly.  The  strength  one 
can  use  on  different  patients  and  different  teeth  varies 
according  to  the  resistance,  and  also  on  whether  one  uses 
the  negative  pole  in  close  proximity  to  the  positive  or  far 
away  from  it. 

The  sterilization  of  root  canals  will  be  also  briefly 
considered. 

The  question  is  often  asked,  "What  is  a  definition  of 
an  ion?"  An  ion  is  the  product  of  decomposition  when 
substances  are  broken  into  their  elements.  It  may  be 
further  asked,  "Why  do  ions  cure  pyorrhea?"  In  the 
first  place  these  products  of  decomposition  are  carried 
with  the  electric  current,  or  they  are  parts  of  the  things 
which  move  between  the  two  poles.  The  medicine  goes 
deeply  into  the  tissue.  It  does  not  stay  on  the  surface, 
and  one  does  not  have  to  depend  on  absorption  locally. 
There  is  no  reaction  afterwards.  The  writer  once  had 
reaction  when  he  first  used  cocain,  because  of  faulty  tech- 
nic.  Great  care  in  technic  is  necessary.  One  can  co- 
cainize a  part  so  that  one  can  lance  an  abscess  beauti- 
fully, but  the  region  anesthetized  is  only  as  great  as  the 
area  of  the  electrode  with  which  it  has  contact. 

Positive  Results  in  Pyorrhea.— The  positive  results  of 
this  treatment  in  pyorrhea  are  very  marked.  It  is  the 
very  best  medium  known  of  by  the  writer  for  bringing 
about  cessation  of  pus.  If,  however,  the  patient  does 
not  cooperate  with  the  dentist  there  is  going  to  be  a  re- 
currence. There  never  will  be  a  cure  without  the  co- 
operation of  the  patient.  This  cooperation  consists  of 
cleaning  the  teeth  properly  and  not  leaving  pieces  of 


398         A.DVANCES  IX  DENTAL  SURGERY 

meat  there;  and  of  the  use  of  floss  silk.  Riggs'  Disease 
is  largely  duo  to  neglect.  One  hears  every  day  of  all 
the  horrors  of  pyorrhea  and  that  everybody  has  got  it, 
and  undoubtedly  many  persons  have,  but  proper  co- 
operation and  proper  instruction  on  the  part  of  the 
dental  profession  directed  to  their  patients  will  make  a 
wonderful  change.  One  cannot  cure  this  condition,  how- 
ever, without  eternal  vigilance  on  the  part  of  the  dentist 
and  that  of  his  patient. 

Frequency  of  Treatment.— As  regards  this  point  many 
patients  come  once  in  three  months,  and  to  all  intents 
and  purposes  they  are  cured ;  they  do  not  accumulate  tar- 
tar the  way  they  used  to,  and  they  do  take  care  of  their 
teeth.  The  most  potent  factor  in  making  people  take 
care  of  their  teeth  and  their  mouths,  after  one  has  proven 
treatments  beneficial,  is  to  make  one's  fees  large  and 
so  increase  their  appreciation. 

Current.— In  regard  to  the  current  one  can  use  an  alter- 
nating current,  but  it  must  be  converted.  The  writer  uses 
a  continuous  flowing  current,  or  galvanic  current  and 
zinc  electrodes.  The  minute  the  current  starts  flowing 
the  electrodes  disintegrate;  salts  develop  immediately 
the  current  is  turned  on,  and  are  applied  not  only  to  the 
tissue  but  into  the  tissue,  and  that  is  how  they  accom- 
plish the  result. 

Iodin. — In  regard  to  iodin,  it  is  excellent  for  applica- 
tions externally;  that  is,  to  mucous  membrane.  Iodin  is 
used  on  the  negative  pole ;  that  is  the  only  thing  used  in 
dentistry  which  is  electronegative. 

Root  Canals.— In  the  treatment  of  root  canals  either 
zinc  chlorid  or  common  salt  solution  is  used;  the  latter 
breaks  up  into  sodium  and  chlorin  gas;  that  is  the  only 
thing  that  wrill  sterilize  the  root  canal  structure  to  any 
depth  and  that  outweighs  all  drugs  one  has  ever  used 
in  root  canal  work  so  far  as  efficiency  is  .concerned.  It 
is  more  potent  than  any  of  them.  A  one  or  a  two  per 
cent  salt  solution  is  used  and  broken  up  with  the  electric 


IONIZATION  399 

current  which  is  allowed  to  run  up  to  the  point  of  sen- 
sation (anything  from  one  to  three  or  four  amperes), 
and  if  one  is  ingenious  one  can  hold  that  electrode  in  the 
canal  by  mechanical  means,  but  it  must  not  touch  any 
other  thing  before  entrance  to  the  canal.  If  tried, 
the  strong  smell  of  chlorin  gas  after  two  or  three  min- 
utes '  run  of  that  current  will  be  noted.  That  is  a  recent 
method  of  sterilizing  root  canals.  Tf  one  has  no  board 
one  has  to  do  the  best  one  can  with  any  other  method 
one  knows  about. 

Reinfection.— In  regard  to  reinfection  the  author  has 
never  had  any  cases  that  he  knows  of,  but  that  does  not 
say  that  some  of  the  cases  ionized  have  not  gone  to  some 
other  dentist.  Excellent  success  has  been  obtained  with 
other  methods,  but  every  root  canal  is  ionized  before  it 
is  filled  in  the  writer's  present  practice.  Immediately 
after  sterilizing  the  root  is  filled.  If  it  is  a  very  putres- 
cent root  three  treatments  of  the  salt  solution  are  given 
and  then  those  canals  are  filled.  The  canals  are  sealed 
with  dry  sterile  points.  It  is  an  amazing  thing  that  one 
can  seal  that  in  without  any  drug  on  it,  and  see  how  soon 
it  becomes  sweet.  The  canal  is  filled  up  after  the  removal 
of  the  live  pulp,  but  usually  after  one  dressing,  which  is 
left  in  a  couple  of  days.  There  is  always  more  or  less 
hemorrhage,  and  the  dry  dressing  is  left  in  there  to  sop 
up  what  it  will.  That  canal  gets  only  one  treatment. 
With  an  open  foramen  the  patient  will  not  stand  so  much 
as  if  the  foramen  is  closed  up. 

Desensitizing  Dentin. — In  this  procedure  the  writer 
uses  eocain  in  the  form  of  Schieffelin's  neurocain  tablets; 
that  is,  in  places  where  cervical  cavities  are  accessible 
and  can  be  isolated  and  kept  dry  a  matter  of  two  or  three 
minutes.  The  technic  in  question  is  a  difficult  one,  be- 
cause it  is  fussy.  The  eocain  is  placed  in  the  cavity,  and 
on  top  of  that  a  small  pledget  of  cotton  moistened  in 
water  is  placed.  Upon  that  a  piece  of  gold  or  platinum 
foil  larger  than  the  cavity  is  put,  and  then  the  electrode 


400        ADVANCES  IN  DENTAL  SURGERY 

placed  on  that  and  run  for  30  seconds.  If  one  runs  over 
that  time  the  pulp  is  cooked  and  made  snow-white,  which 
means  pulp  removal.  This  method  is  used  to  coagulate 
the  albumin.  If  one  takes  a  raw  egg  and  puts  the  posi- 
tive pole  to  the  egg  it  coagulates  just  as  though  put  into 
boiling  water.  It  is  the  greatest  styptic  known  for  stop- 
ping a  hemorrhage  in  a  root  canal.  In  ionization,  for  de- 
sensitizing the  positive  pole  is  put  on  until  the  patient 
feels  it.  Sometimes  after  a  tenth  of  a  milli-ampere  the 
patient  will  feel  it.  The  pole  is  just  left  there.  The  mo- 
ment the  current  is  started  it  is  felt,  but  one  does  not 
have  to  hurt  the  patient  with  this  technic  at  all. 


CHAPTER  XVI 

MILITARY  ADMINISTRATION 
Major  Frederick  E.  Jones,  U.S.A. 

This  chapter  purports  to  explain  some  of  the  customs 
of  the  service  and  to  indicate  various  sources  from  which 
the  military  dentist  may  obtain  necessary  information. 
It  is  going  to  be  necessary  for  the  future  army  dentist  at 
some  point  to  receive  military  instruction,  and  Den- 
tal Reserve  Corps  Surgeons  will  be  unfortunately  so 
situated  that  probably  no  instruction  will  be  given  them 
in  a  great  many  things  that  they  ought  to  know.  Military 
life  is  very  different  from  civilian  life.  Things  that  one 
has  learned  in  civilian  life  will  have  to  be  changed  rather 
radically.  It  is  therefore  a  necessity  for  the  aspirant  to 
a  commission  as  army  dentist  to  know  something  about 
what  is  expected  of  him  from  a  military  standpoint. 
Doubtless  there  will  be  many  applications  for  commis- 
sions in  the  Dental  Reserve  Corps. 

Application  for  U.  S.  D.  R.  C— This  entails  upon  the 
candidate  certain  required  things  before  he  goes  into  the 
service.  In  the  first  place,  he  makes  an  application  for  a 
commission  in  the  Dental  Reserve  Corps.  Later,  notice 
is  sent  that  he  is  to  appear  at  a  certain  time  and  at  a  cer- 
tain place  to  be  examined,  both  physically  and  mentally, 
for  his  commission. 

PHYSICAL  EXAMINATION  AND   REQUIREMENTS 

The  physical  examination  is  easy;  it  is  applied  to 
every  soldier  or  officer  entering  the  Army  and  has  certain 

401 


402  MILITARY  ADMINISTRATION 

requirements  which  are  not  absolutely  invariable.  The 
personal  element  in  the  examiner  lias  a  great  deal  to  do 
with  the  examination  of  the  officer  or  recruit.  The  exam- 
ination for  both  is  the  same.  Some  of  the  requirements 
of  the  physical  examination  will  be  enumerated. 

Chest  Measure.— In  the  first  place,  the  minimum  re- 
quirement for  chest  measurement  is  32  inches.  The  ap- 
plicant must  have  an  expansion  over  that  of  2  inches.  It 
makes  no  difference  whether  in  his  effort  to  show  what 
wonderful  bellows  he  has  he  gets  down  to  29  inches  or 
not.  His  normal  range  is  required,  and  that  in  the  min- 
imum range  is  expiration  .32  and  inspiration  34  inches. 
If  32  inches  is  multiplied  by  2,  one  gets  64  inches,  which  is 
the  minimum  required  for  height. 

Height.— The  applicant  must  be  5  feet  4  inches  in 
height.  Even  the  height  of  5  feet  4  inches  has  been 
waived  in  some  cases  by  the  Adjutant  General  when  the 
applicant  has  shown  marked  ability,  and  when  the  height 
waived  was  but  slightly  below  64  inches.  A  fraction  of 
an  inch  is  counted  as  a  whole  inch  or  no  inch  at  all.  For 
instance,  5  feet  3%  inches  would  represent  5  feet  4  inches, 
and  5  feet  3%  inches  would  represent  5  feet  3  inches  in 
height.     That  covers  the  subject  of  height. 

Weight.— If  64  inches  is  multiplied  by  2,  128  inches  is 
obtained,  which  is  the  minimum  weight  in  pounds  of  the 
applicant,  stripped.  There  are  various  exceptions  to 
that.  A  man  may  be  muscular,  but  thin  and  slight,  and 
very  desirable  both  as  a  recruit  or  as  an  officer;  and  a 
certain  variation  is  therefore  allowed.  The  extreme 
variation  is  8  pounds  less  than  128  pounds,  bringing  the 
minimum  weight  down  to  120. 

Vision.— The  reasons  for  which  men  and  officers  are 
most  frequently  rejected  in  the  physical  examination  are, 
beginning  at  the  head,  the  eyes.  The  requirement  for 
vision  is  20/40  in  the  right  eye  and  20/100  in  the  left,  or 
one-half  normal  vision  in  the  right  eye  and  one-fifth  in 
the  left  eye.    It  is  astonishing  to  find  how  many  men  have 


PHYSICAL  REQUIREMENTS  403 

not  even  that  amount  of  vision.  They  are  examined  at  a 
distance  of  20  feet.  In  the  later  orders,  however,  even 
that  requirement  is  further  qualified,  in  that  it  is  stated : 

Any  officer  who  has  not  distinctly  bad  vision  and  whose  vision 
is  corrected  to  the  normal  by  glasses,  may  be  accepted. 

Teeth.— Many  men  fail  on  account  of  their  teeth.  Or- 
ders require  that  a  candidate  must  have  four  opposing 
molars.  If  he  has  four  opposing  molars  that  is  enough. 
That  looks  like  a  mighty  small  amount  of  teeth,  but  that 
is  all  that  is  required.  If  those  molars  were  in  fair 
shape,  he  could  punch  holes  through  all  the  hard-tack 
they  gave  him.  Plates  or  other  artificial  teeth  are  not 
officially  recognized  as  being  teeth.  Later,  at  the  end  of 
the  examination,  when  it  is  found  that  the  only  fault  is 
a  few  teeth  missing,  the  examining  officer  makes  a  state- 
ment to  the  effect  that  the  applicant  has  no  other  physical 
disability  except  the  missing  teeth,  and  of  course  a  record 
of  each  tooth  is  kept. 

Heart.— YVh en  the  men's  chests  are  examined  one  finds 
that  many  are  rejected  on  account  of  heart  trouble.  It  is 
rare  that  any  difficulty  in  a  man's  lungs  is  found;  that  is, 
a  man  is  not  rejected  for  that  reason.  So  many  men 
come  with  ordinary  colds  which  look  so  much  like  tuber- 
culosis of  the  lungs  that  men  are  rarely  rejected  on  ac- 
count of  such  symptoms ;  but  in  the  case  of  a  man's  heart, 
many  lesions,  particularly  valvular,  are  found.  These 
cases  are  always  rejected.  It  is  rare  that  one  has  been 
able  to  dodge  rejection  who  has  a  valvular  lesion  of  the 
heart.  There  is  a  good  reason  why.  Under  the  hard 
strain  of  field  service  those  hearts  break  down,  and  then 
there  are  cripples  to  be  taken  care  of.  Not  only  the  man 
afflicted  is  lost,  but  also  someone  has  to  take  care  of  him. 

Hernia. — A  man  is  always  rejected  if  he  has  hernia, 
for  the  reason  that  in  the  field  those  hernias  are  apt  to 
break  down  under  the  physical  strain  of  hard  field  serv- 
ice and  the  patient  may  be  in  a  position  where  no  proper 


404  MILITARY  ADMINISTRATION 

medical  aid  can  reach  him  to  reduce  that  hernia.  Hernias 
practically  always  eliminate  a  man  in  his  physical  exam- 
ination. 

There  is  little  else  to  say  in  regard  to  the  physical 
examination  except  that  a  man  is  rejected  for  such  things 
as  extensive  varicose  veins. 

Flat  Feet.— A  great  many  men  are  rejected  for  flat  feet, 
but  not  so  many  as  formerly.  Flat  feet  are  not  a  cause 
for  rejection,  if  they  do  the  work  as  well  as  high  arches. 
The  thickset  type  of  man  often  has  flat  feet.  It  has  been 
found  in  the  field  that  those  men  who  have  flat  feet  are 
likely  to  get  along  as  well  as  men  with  high  arches.  The 
high  arch  might  break  down  as  soon  as  its  owner  gets 
into  the  field.  This  makes  little  difference,  however,  for 
in  a  month's  time  under  good  care  he  will  have  an  arch 
that  can  hardly  be  broken  down.  He  makes  the  best 
man  after  he  is  seasoned  and  hardened.  So  much  for  the 
physical  examination.  There  are  a  great  many  errors 
to  look  for,  and  many  are  usually  present,  for  the  perfect 
man  has  never  been  found. 

Mental  Examination 

The  mental  examination  merits  but  little  attention  in 
these  pages.  One  need  have  no  fear  regarding  it.  A 
dentist  who  can  go  before  the  examining  board  and  pre- 
sent a  diploma  from  a  recognized  dental  school  and  a 
certificate  from  the  state  that  he  is  a  practicing  dentist 
should  pass  the  board  almost  invariably.  That  man  has 
nothing  to  fear  before  the  board  of  examiners.  He  may 
go  before  them  and  have  an  attack  of  nerves  and  not  be 
able  to  tell  his  own  name,  but  he  is  rarely  rejected  for 
that  reason.  The  examiner  realizes  his  condition.  For 
that  reason  the  average  dentist  should  have  no  fear  when 
he  goes  before  the  examining  board.  He  should  go  before 
them  squarely  and  do  the  thing  that  is  asked  quietly  and 
easily;  he  need  not  be  excited;  excitement  destroys  a 


TYPHOID  INOCULATION  405 

man's  judgment  so  that  he  cannot  do  things  right.  The 
candidate  who  has  had  reputable  dental  training  and 
who  goes  before  the  board  willingly  and  calmly  with  the 
purpose  of  telling  what  he  is  asked  to  tell  rarely  fails  to 
pass. 

Having  passed  these  two  examinations,  there  is  noth- 
ing, for  a  man  to  do  except  to  wait  for  the  Government 
to  appoint  him  as  a  first  lieutenant  in  the  Dental  Reserve 
Corps.  When  the  Government  has  need  of  him,  he  will 
receive  his  appointment.  Later  on  a  commission  will  come 
along,  signed  by  the  President  of  the  United  States, 
showing  that  he  is  a  first  lieutenant  in  the  Dental  Re- 
serve Corps.  He  will  ask,  "When  do  I  go  into  service?" 
No  one  knows  when  he  will  go  into  service.  When  the 
Government  gets  ready,  the  man  will  go.  Where  ?  Any- 
where the  Government  sees  fit  to  send  him.  There  is  no 
choice  in  the  matter;  one  goes  wherever  he  is  sent.  Of 
course  it  takes  months  and  even  years  to  make  a  full 
fledged  military  man,  but  the  most  essential  points  may 
be  learned  in  less  time  than  that. 


TYPHOID    INOCULATION 

After  the  candidate  has  passed  thejnental  and  phys- 
ical examinations,  he  is  inoculated  against  typhoid  fever. 
Those  who  have  been  fighting  typhoid  in  the  United 
States  Army  know  the  necessity  for  inoculation.  When 
men  are  collected  together  in  large  numbers,  contagious 
disease  flies  through  them  like  wildfire.  For  that  reason 
typhoid  fever  has  been  the  scourge  of  armies.  The  prev- 
alent method  of  inoculation  is  to  inject  half  a  billion,  or 
a  whole  billion,  of  dead  typhoid  bacteria  at  weekly  inter- 
vals, which  usually  gives  the  desired  immunity  against 
disease.  Many  people  today,  going  on  their  summer 
vacations,  take  their  typhoid  prophylaxis  for  the  reason 
that  so  manv  have  died  from  drinking  infected  water  and 


406  MILITARY  ADMINISTRATION 

eating  infected  food.  Most  people  are  vaccinated  against 
smallpox.  By  inoculating  against  typhoid  and  vaccin- 
ating against  smallpox  much  has  been  accomplished  to 
save  men.  The  inoculation  against  typhoid  is  not,  how- 
ever, an  absolute  preventive.  Last  year  there  was  a  case 
in  the  hospital  where  a  man  had  been  inoculated  perfect- 
ly and  the  doctor  said  it  was  a  case  of  typhoid.  It  did  not 
seem  possible,  yet  in  due  time  a  pure  culture  of  typhoid 
appeared.  While  in  Mexico  it  is  said  that  General  Persh- 
ing sent  up  fifteen  cases  which  were  suspicious,  all  of 
which  had  true  typhoid  fever.  Later  there  were  found 
several  cases  of  paratyphoid,  all  of  which  were  mild. 
One  should  inoculate  against  paratyphoid  in  an  area 
where  paratyphoid  exists.  The  prophylaxis  for  many 
other  diseases  has  not  yet  been  found.  A  great  many 
cases  of  typhus  fever  were  observed  among  the  Mexicans, 
but  by  good  sanitation,  cleanliness  and  willingness  to  do 
the  right  thing,  the  disease  was  kept  out  of  the  army 
camp. 

UNIFORM    AND    EQUIPMENT 

The  Uniform 

The  next  thing  to  be  considered  is  the  equipment  that 
a  man  should  have  in  going  into  the  field.  It  is  probably 
well  known  that  orders  have  been  issued  that  no  uniform 
shall  be  worn  now  but  the  service  uniform,  except  in  the 
White  House.  This  applies  to  such  organizations  as  the 
Ancient  and  Honorable  Artillery,  who  are  often  seen 
marching  through  the  streets  in  their  dress  uniforms. 
The  dress  uniform  is  slightly  different  from  the  field 
service  uniform.  The  field  service  uniform  consists  of  a 
pair  of  riding  breeches  and  a  blouse.  It  is  the  so-called 
O.D.  (olive  drab)  uniform. 

Payment  for  Uniforms.— In  the  first  place,  officers  pay 
for  everything.  The  enlisted  man  has  everything  given 
to  him.    An  officer  may  borrow  from  the  Government  on 


UNIFORM  AND  EQUIPMENT  407 

memorandum  receipts,  so-called,  a  large  list  of  supplies 
needed  in  the  field.  That  means  supplies  are  loaned 
but  one  must  pay  them  back  or  send  them  back  some  day. 
If  one  does  not,  he  will  be  charged  with  the  item  or  items 
and  must  pay  for  them.  Loss  is  no  excuse.  Any  rem- 
nants are  handed  back  and  are  of  great  value,  because 
the  remnant  which  one  may  hand  back  is  worth  just  the 
same  to  the  accounts  as  the  original  article.  It  is  better 
to  buy  a  good  uniform  and  to  always  have  that  feeling 
that,  if  one  wants  to,  he  can  look  like  a  gentleman  again. 
Get  clothes  that  fit.  There  is  a  regular  issue  of  clothing 
which  is  good  enough  for  the  field.  After  one  has  rolled 
around  in  the  dirt,  wrapped  up  in  a  poncho,  he  does  not 
need  white  collars  and  cuffs.  All  this  goes  to  show  that 
there  is  a  certain  psychology  of  clothes  in  the  Army.  It 
is  therefore  advised  that  all  who  get  their  commissions 
should  immediately  go  to  a  good  tailor  and  have  a  first 
class  uniform  made.  Then  the  enlisted  man's  uniform 
can  be  bought  at  cost  price,  and  it  can  be  made  over  by  a 
tailor. 

Horse. — Every  officer  in  the  medical  and  dental  depart- 
ment is  mounted.  Everyone  is  supposed  to  get  a  horse. 
A  horse  is  issued  by  the  Government  on  a  memorandum 
receipt.  One  must  be  sure  to  bring  him  back,  because  his 
value  is  stated  in  the  book  as  $141.27,  or  whatever  it  may 
be.  If  one  does  not  bring  him  back,  he  is  not  asked  to  pay 
for  him;  the  authorities  simply  extract  it  from  the  man's 
salary  and  hand  him  the  remainder. 

Field  Equipment 

Next  let  us  look  through  the  list  and  see  what  an 
officer  is  to  take  into  the  field  with  him.  One  must  have 
some  sort  of  equipment  whereby  he  can  eat  when  he 
goes  out  into  the  field. 

The  official  list,  issued  May  17,  1917,  gives  a  table  of 
things  which  an  officer  should  have. 


408  MILITARY  ADMINISTRATION 

Saddle-bags.— Utensils  are  slipped  into  the  saddle-bag, 
which  is  on  the  left-hand  side  of  the  horse.  Every  horse 
has  a  right  side  and  a  wrong  side.  He  is  not  approached 
on  the  right  side,  bnt  on  the  left  side.  That  may  be  a  way 
to  help  remember  it.  The  saddle-bags  hang  behind  the 
saddle,  one  on  each  side.  In  the  nigh-side  bag  are  the 
rider's  equipments,  and  the  horse's  are  in  the  one  on  the 
off  side.  The  horse  has  extra  shoes,  curry-comb,  brush, 
surcingle,  watering  bridle  and  a  halter.  Those  are  on 
the  off  side.  One  should  not  make  the  common  mistake  of 
approaching  the  horse  on  the  off  side. 

Care  of  Horse.— If  a  horse  has  been  brought  up  in  the 
army,  he  has  been  taught  by  experience  to  take  care  of 
himself.  That  means  he  uses  his  mouth  and  his  heels 
and  he  bucks  and  does  a  lot  of  things  like  that  to  take 
care  of  himself.  If  a  horse  is  not  acting  normally,  his 
rider  can  be  sure  that  he  needs  food  or  water  or  some  of 
the  other  essentials.  His  horse  is  a  man's  best  friend  in 
the  service.  One  may  need  him  for  only  half  an  hour,  but 
when  he  does,  it  may  be  very  badly.  He  must  be  ap- 
proached on  the  nigh  side;  never  riled;  and  it  is  neces- 
sary to  see  that  he  is  fed  and  watered  properly ;  that  he 
is  properly  cleaned;  and  that  the  saddle  fits  correctly. 
A  man  must  make  a  good  friend  out  of  his  horse ;  for  if 
he  overlooks  any  of  these  details,  he  is  pretty  sure  to 
be  reminded  some  day,  because  the  horse  knows  after  a 
while  that  his  rider  is  responsible  for  him.  If  the  horse 
is  not  treated  well,  the  rider  is  the  only  one  he  can  notify, 
and  he  has  only  one  or  two  ways  in  which  he  can  do  this. 

Eating  Utensils.— First  there  is  a  small  can,  costing 
twenty  cents,  in  which  to  keep  bacon.  That  can  be  put 
into  the  saddle-bag;  next  a  condiment  can,  costing  thir- 
teen cents ;  then  the  canteen,  price  sixty-one  cents.  There 
is  an  aluminum  canteen  with  screw  cap  top.  It  is  a  very 
good  one.  It  is  provided  with  an  outside  covering  of  felt- 
ed canvas  which  protects  the  canteen  in  much  the  same 
way  as  a  thermos  bottle.    To  cool  the  canteen,  the  outside 


UNIFORM  AND  EQUIPMENT  400 

is  wetted  and  the  evaporation  through  the  felt  and  canvas 
will  cool  the  water.  The  canteen  will  not  stand  being 
rolled  on  by  the  horse.  If  rolled  upon,  it  will  bend,  in 
which  case,  one  must  get  a  new  one.  One  can  always  get 
a  new  for  an  old  canteen,  no  matter  how  badly  damaged 
it  may  be.  An  aluminum  cup  fits  over  the  base  of  the 
canteen.    That  cup  sells  for  thirty-five  cents. 

One  has  also  to  have  a  knife,  fork  and  spoon  similar  to 
those  used  at  home,  but  it  must  be  said  that  they  are  sim- 
ilar only  in  shape  and  not  quality  or  comfort.  The  knife 
costs  twelve  cents;  the  fork,  seven  cents;  spoon,  seven 
cents.  They  are  a  very  efficient  knife,  fork  and  spoon, 
and  for  a  while  a  man  has  a  lot  of  exercise  with  them, 
more  exercise  than  riding  a  horse.  They  are  provided 
with  a  container  in  which  they  may  be  rolled  quite  tightly 
together  and  carried  inside  the  saddle-bag. 

Dismounted  officers  carry  a  haversack,  which  hangs  by 
the  side  from  a  strap  over  the  shoulder.  As  a  mounted 
officer,  one  does  not  have  the  privilege  of  carrying  that 
over  the  shoulder.  The  articles  ordinarily  contained  in 
a  haversack  by  a  dismounted  officer  will  be  kept  by  a 
mounted  officer  in  his  saddle-bag. 

First-aid  Packet.— One  thing  that  every  officer  and 
man  must  have  is  his  first-aid  packet.  This  is  a  little 
metal  case,  containing  two  compressed  sterilized  ban- 
dages with  gauze  streamers  attached,  safety  pins,  and  a 
printed  sheet  of  directions.  This  little  package  is  car- 
ried on  the  left-hand  side,  slipped  into  a  pouch.  The 
matter  of  carrying  this  packet  is  watched  by  the  Govern- 
ment very  carefully.  The  inspecting  officers  look  over 
each  man's  equipment,  and  make  a  very  definite  report, 
on  four  separate  copies,  of  everything  a  man  has  not  that 
he  should  have.  Later  he  will  hear  from  the  authorities 
about  it. 

Pistol,  etc.— The  pistol  holster  and  pistol  are  not  neces- 
sary unless  one  is  in  the  region  where  the  rules  of  the 
Geneva  Convention  are  not  observed.     There  are  por- 


410  MILITARY  ADMINISTRATION 

tions  of  Mexico  where  one  would  probably  have  to  have 
a  pistol.    It  is  a  very  desirable  adjunct  to  the  equipment. 

Obtained  from  Ordnance  Department.— All  this  prop- 
erty of  which  mention  has  been  made  is  called  ordnance 
property.  And  here  the  writer  must  begin  to  touch  on 
something  in  regard  to  the  part  which  the  Departments 
play  in  army  life.  A  dental  officer  is  affected  by  the  Ord- 
nance Department,  the  Medical  Department,  and  the 
Quartermaster's  Department,  and  he  may  have  accounts 
with  all  three.  There  is  hardly  any  one  subject  in  this 
whole  course  that  is  going  to  be  so  necessary  for  officers 
to  observe  as  the  subject  of  Departments.  Just  the  mo- 
ment an  article  leaves  their  hands,  it  is  charged  to  the  re- 
cipient. The  onus  of  obtaining  it  is  on  him.  From  that 
time  he  is  held  responsible  for  this  article  until  he  gets  a 
receipt  for  it.  If  he  does  not  turn  it  back  or  does  not  find 
the  proper  way  of  avoiding  loss,  the  value  is  subtracted 
from  his  pay.  The  articles  before  enumerated  are  en- 
tirely equipment  from  the  Ordnance  Department  which 
each  officer  will  need.  Practically  all  of  them  can  be  ob- 
tained on  memorandum  receipt.  Most  men,  however, 
prefer  to  buy  them  for  cash  at  whatever  supply  depot 
happens  to  be  nearest,  and  think  no  more  about  it.  They 
then  belong  to  the  buyer.  The  Government  price  is  so 
low  that  it  costs  but  a  moderate  amount  to  buy  them. 

From  Quartermaster's  Department. — From  the  Quar- 
termaster's Department  one  may  obtain  on  memorandum 
receipt  certain  other  articles  which  are  more  or  less  es- 
sential. 

Mosquito  Bar.  — The  first  of  these  is  the  mosquito  bar, 
price  $2.29.  It  is  said  by  one  officer  of  the  Medical  De- 
partment that  he  never  was  among  men  of  such  high  rank 
as  on  one  trip  in  the  Philippines  when  he  went  with  a 
division  with  its  headquarters  on  an  excursion  through 
one  of  the  islands.  He  was  the  only  officer  who  had  a 
mosquito  bar.  They  met  a  lot  of  mosquitoes  of  the  mala- 
ria breeding  kind.     The  result  was  that  he  lay  at  night 


UNIFORM  AND  EQUIPMENT  411 

under  his  mosquito  bar  with  the  head  of  a  lieutenant 
general  here  and  the  head  of  a  major  general  there;  in 
fact,  he  was  lined  with  the  heads  of  officers.  They  only 
asked  to  be  allowed  to  put  their  heads  under  the  netting 
and  they  could  let  the  rest  of  their  bodies  take  care  of 
themselves.  The  mosquito  bar  is  very  essential.  It  is 
nothing  but  mosquito  netting  which  is  suspended  when 
one  wishes  to  go  to  sleep.  The  top  of  the  bar  is  spread 
about  two  feet  above  and  the  sides  fall  around  the  cot 
bed,  if  one  has  one.  The  mosquito  bar  is  always  ready  for 
use.  Generally  in  the  summer  time  one  will  meet  mos- 
quitoes to  which  he  will  have  to  pay  some  attention. 

Bedding  Roll.— The  bedding  roll  is  some  sort  of  canvas 
container  in  which  one  carries  bedding  and  on  which 
or  in  which  he  sleeps.  There  are  a  number  of  different 
kinds.  The  writer  uses  a  piece  of  good  heavy  khaki 
canvas  9  ft.  by  9  ft.,  and  of  course  fellows  who  have 
been  out  a  good  many  times  have  pretty  definite  ideas 
about  what  they  ought  to  have.  Nine  ft.  by  9  ft.  is  just 
the  size  of  the  floor  of  a  wall  tent.  When  the  quar- 
ters are  first  made  the  bedding  is  all  rolled  up  in  this 
canvas  inside  the  tent.  The  ropes  are  untied  and  a 
kick  spreads  it  out  to  stay  there  for  a  tent  floor.  An  offi- 
cer gets  a  low  cot  bed.  The  cot  is  set  up  on  one  side  of 
the  tent,  and  the  bedding  is  taken  out  of  the  roll.  One 
first  takes  out  the  poncho,  which  is  a  rubber  blanket, 
then  the  army  blankets  and  usually  nice  white  sheets 
and  a  pillow  case  when  possible.  A  pillow  should  always 
be  brought.  There  is  nothing  in  the  regulations  about 
pillows.  Oftentimes  a  martinet  will  decide  that  pillows 
are  not  a  part  of  an  officer's  equipment,  but  they  can  be 
hidden.  It  is  a  good  deal  of  comfort  to  get  between 
sheets,  so  that  when  the  bed  is  spread  there  is  a  very  re- 
spectable looking  tent.  Generally  the  bedding  roll  is  so 
made  that  a  man  may  make  a  sleeping  bag  out  of  it.  At 
the  top  and  bottom  are  flaps  which  can  be  used  as  clothing 
containers.    They  keep  the  clothing  flat  and  dry.     These 


412  .MILITARY  ADMINISTRATION 

clot  hi  hi;-  rolls  usually  have  a  very  thin  mattress  in  thorn, 
and  they  are  very  comfortable  indeed.  When  one  breaks 
camp,  he  throws  the  clothing  into  the  bags  at  each  end, 
folds  them  in  and  rolls  up  the  bedding  all  ready  i'or  the 
quartermaster's  wagon  to  load  it  when  it  comes  along. 
In  the  field  an  officer  is  allowed  only  50  lbs.  of  bedding. 
When  a  man  appreciates  how  small  an  amount  50  lbs.  is, 
he  will  find  it  quite  a  problem  to  keep  the  bedding  to  the 
required  weight.  Eliminating  the  cot  bed,  the  bedding  roll 
will  weigh  10  or  12  lbs.  When  it  is  considered  that  every 
single  thing  has  to  go  into  that  roll,  it  is  apparent  that 
one  has  to  figure  pretty  closely.  For  cold  weather,  a  down 
puff  weighs  almost  nothing,  and  it  is  twice  as  warm  as 
any  blanket.  In  the  field  one  sees  all  sorts  of  officer's 
equipment.  It  is  surprising  to  see  how  many  makeshifts 
there  are.  An  officer  knows  how  to  be  comfortable 
through  long  experience,  and  does  not  always  follow  the 
idea  of  the  Government.  The  Government  bedding  roll 
costs  $6.52.  The  blankets  one  can  borrow  on  memoran- 
dum receipt  or  buy  from  the  supply  depots  for  $3.08. 

Basin  and  Bathing. — A  canvas  basin  is  necessary, 
which  is  much  like  a  canvas  bucket.  That  gives  some- 
thing to  wash  in.  Speaking  of  bathing,  it  is  a  fact  that 
the  army  officers  often  bathe  of  necessity  in  other  liquids 
than  water.  There  are  places  in  Texas  where  there  is  no 
water  within  one  hundred  miles.  There  are  places  there 
where  there  is  no  record  of  rain  ever  having  fallen.  When 
water  is  found  there  is  sometimes  nothing  but  a  hole  with 
alkali  standing  in  it,  like  snow,  perhaps  three  or  four 
inches  thick.  It  is  undrinkable,  and  there  is  nothing  to  do 
but  start  off  for  the  next  hole.  Water  is  sure  to  be  scarce 
in  any  campaign.  City  water  cannot  be  piped  to  each 
tent.  A  division  contains  about  20,000  men  on  the  march 
and  a  great  number  of  animals.  All  these  men  and  ani- 
mals must  be  watered  at  least  twice  a  day.  The  writer 
has  seen  a  division  watered  when  twenty-two  cocks  were 
running  continuously  for  two  hours,  and  even  then  the 


UNIFORM  AND  EQUIPMENT  413 

troops  were  not  sufficiently  watered.  What  is  to  be  done 
with  an  army  of  150,000  men?  Where  is  the  water  com- 
ing from?  In  New  England  there  are  streams  running 
everywhere.  But  in  service,  water  of  any  kind  is  all  one 
expects  to  get,  in  many  places,  so  one  carries  water  as 
best  he  can.  The  time  to  keep  water  is  while  on  the 
march;  when  the  march  is  over  is  the  time  to  drink  it. 
The  writer  has  heard  a  horse  with  water  thrashing 
around  in  his  stomach;  that  is  just  what  happens  to  a 
man  if  he  drinks  early  in  the  march.  When  starting  out 
on  a  long  march  in  warm  weather,  water  should  be  saved 
until  the  march  is  over. 

It  is  well  not  to  bathe  too  carefully  in  the  morning,  for 
the  reason  that  one  may  wash  off  that  oily  secretion  of 
the  skin  which  saves  from  sunburn.  It  is  not  necessary 
to  rub  the  hide  off,  but  just  to  rub  lightly  with  water,  leav- 
ing on  the  oily  secretion  of  the  skin.  When  one  finishes 
the  march  at  night  it  does  not  take  much  to  get  a  bath. 
The  writer  is  known  as  the  fellow  who  can  shave,  treat  a 
sunburn,  and  bathe  out  of  a  bottle  of  beer  and  have  half 
the  bottle  left  to  drink  when  he  gets  through.  This  seems 
like  a  fairy  story,  but  if  you  think  it  over  for  a  minute 
you  will  remember  that  though  one  cannot  get  any  water, 
a  bottle  of  beer  can  almost  invariably  be  obtained.  The 
writer  has  been  on  half  a  dozen  campaigns  where  there 
was  no  water,  but  there  was  always  a  bottle  of  beer.  No 
one  knows  how  it  got  in,  but  it  was  always  there.  It  can 
easily  be  seen  that  it  does  not  take  very  much  to  wash  in 
in  the  afternoon  after  coming  in  hot,  dirty  and  tired, 
nursing  that  one  bottle  of  beer  and  thinking  what  a  good 
time  was  coming.  A  man  can  get  out  his  toothbrush,  put 
a  little  beer  on  the  brush  and  clean  his  teeth  thoroughly ; 
he  can  then  shave  carefully ;  perhaps  he  finds  he  is  some- 
what sunburned;  some  of  the  beer  can  be  very  carefully 
rubbed  into  the  face ;  then  it  is  rubbed  off  with  a  towel ; 
next  he  can  strip  off,  and  take  a  little  of  the  beer  in  the 
hand  and  go  over  the  body;  then  he  can  take  a  towel  and 


414  MILITARY  ADMINISTRATION 

rub  down.  There  is  half  a  bottle  left  ready  to  finish  the 
job ;  and  no  idea  can  be  formed  as  to  how  finely  it  tastes ! 
That  story  has  a  moral.  One  can  do  a  thousand  and  one 
things  in  military  life  that  in  civilian  life  he  would  think 
were  impossible.  The  writer  has  been  on  the  march  when 
he  thought  he  was  going  to  fall  the  next  minute.  The 
thermometer  stood  at  120° ;  his  head  was  spinning 
around,  heat  waves  coming  up  before  his  eyes,  but  he 
survived.  One  must  not  be  discouraged,  then,  at  mere 
absence  of  water. 

Sometimes  it  is  necessary  to  eliminate  much  of  the 
equipment.  If  not,  the  horse  is  liable  to  have  saddle  galls 
which  are  going  to  fester.  A  man  must  throw  away  prac- 
tically everything  to  save  his  horse  and  himself.  In  hot 
climates,  why  should  one  need  this  stuff?  Many  officers 
have  gone  for  weeks  in  the  same  clothes,  washed  them  in 
some  stream  and  then  sat  around  on  the  bank  and  waited 
for  them  to  dry  and  felt  just  as  well  afterwards.  One 
learns  to  conserve  a  great  many  things  on  the  march,  and 
a  great  many  situations  will  arise  that  are  unforeseen. 

Bed  Sacks.— There  are  some  other  things  which  come 
from  the  quartermaster's  department;  for  example,  bed 
sacks.  These  are  sacks  filled  with  straw  to  make  mat- 
tresses. These  are  not  satisfactory,  but  are  all  that  is 
provided  for  by  the  government. 

Canvas  Bucket. — A  canvas  bucket  is  very  essential,  and 
also  a  striker  to  furnish  water.  A  striker  is  an  enlisted 
man  to  whom  an  officer  pays  a  certain  amount  of  money 
to  take  care  of  him;  to  see  that  his  clothes  are  in  shape, 
clean  his  horse,  and  so  on.  The  officer  always  pays  that 
striker ;  he  is  not  a  servant  furnished  by  the  Government. 
He  is  a  man  with  whom  an  agreement  is  made.  That  is 
a  very  important  point.  No  enlisted  man  is  a  servant  of 
an  officer,  but  he  may  make  arrangements  with  a  man  to 
do  certain  things.  No  servants  are  provided  by  the  Gov- 
ernment. 

Lantern.— It  is  necessary  to  have  a  lantern,  and  one 


UNIFORM  AND  EQUIPMENT  415 

should  by  all  means  get  one.  If  a  man  does  not  do  so, 
about  the  time  a  light  is  needed  he  will  find  he  cannot  bor- 
row his  neighbor's,  because  the  neighbor  has  only  one. 
So  unless  one  has  a  lantern,  he  will  sit  in  the  dark.  The 
cost  of  a  lantern  is  seventy-five  cents. 

Identification  Tag.— The  identification  tag  is  a  little 
piece  of  aluminum  about  the  size  of  a  quarter  of  a  dollar 
with  a  hole  punched  through  it.  On  it  is  stamped  the 
name,  rank,  and  the  organization  to  which  a  man  belongs. 
This  hangs  around  his  neck  and  comes  down  under  the 
clothing.  When  the  inspecting  officer  comes  around,  it 
must  be  shown  to  him.  It  is  essential  to  have  the  tag  on 
all  the  time. 

Shelter  Tent.— The  shelter  tent,  complete  with  poles 
and  pins,  which  rolls  up  into  a  very  small  package,  costs 
$1.43. 

Poncho.— Next  one  should  have  either  a  poncho  or  a 
slicker.  A  slicker  is  an  oilskin  coat;  the  poncho,  a 
rubber  blanket  with  a  hole  in  the  center,  which  can  be 
used  as  a  raincoat  by  sticking  the  head  through  the  mid- 
dle. For  a  mounted  officer  the  poncho  flaps  too  much.  A 
mounted  man  should  therefore  wear  a  slicker,  which  but- 
tons around  in  front,  and  the  dismounted  man  a  poncho. 
The  saddles  are  always  wet  in  the  rain ;  a  way  has  never 
been  found  to  protect  them. 

Leggings. — A  good  pair  of  puttee  leggings  can  be 
bought  in  any  well-regulated  shoe  store.  A  good  pair 
is  of  English  pigskin.  This  type  just  wraps  around  the 
leg;  there  is  nothing  but  a  slit  at  the  bottom  where 
they  slide  together  and  then  the  strap  holds  them  at 
the  top.  The  writer  advises  getting  the  best  pair  to  be 
found.  They  will  be  needed.  No  officer  should  wear 
enlisted  man's  leggings. 

Underwear. — For  underclothing,  one  can  buy  from  the 
quartermaster:  undershirts,  price  twenty-three  cents; 
drawers,  twenty-two  cents;  stockings,  seven  cents  a  pair. 


416  MILITARY  ADMINISTRATION 

Hat.— In  regard  to  a  hat,  the  service  hat  can  he  bought 
from  the  army  for  $1.04,  and  is  just  as  good  a  cover  in 
the  field  as  any  other.  For  a  dress  hat  one  can  buy  a 
Stetson  for  $5,  in  which  the  quality  of  felt  is  a  little  bet- 
ter. Officers  have  the  habit  of  doing  this.  The  coat  (0. 
D.)  similar  to  this  costs  $.">.5)5;  and  a  cotton  coat  costs 
$1.31.  This  completes  the  necessary  equipment  for  an 
officer. 

Leaving  now  the  qualifications  and  equipment  of  the 
dentist  as  officer  in  the  United  States  Army,  let  us  next 
give  our  attention  to  the  rules  which  govern  him.  The 
following  are  a  few  extracts  from  "Army  Regulations" 
which  is  the  Bible  of  the  Service.  They  will  show  clearly 
what  the  dentist  may  expect  and  also  what  is  expected  of 
him. 

ARMY    REGULATIONS    PERTAINING    TO    THE 
DENTIST  AS  AN   OFFICER  OF  THE  ARMY 

There  are  two  kinds  of  officers,  commissioned  and  non- 
commissioned. A  commissioned  officer  has  his  commis- 
sion given  him  by  the  President,  and  that  commission 
constitutes  his  authority  to  act.  A  non-commissioned  offi- 
cer is  given  a  warrant. 

Articles  of  War 

The  word  "officer,"  as  used  in  the  Articles  of  "War,  shall  be 
understood  to  designate  commissioned  officers ;  the  word  "soldier" 
shall  be  understood  to  include  non-commissioned  officers.  The 
convictions  mentioned  thereunder  shall  be  understood  to  be  con- 
victions by  court-martial. 

Courts. — There  are  three  kinds  of  courts:  general  or 
special  courts-martial  and  summary  courts.  For  minor 
offenses  men  are  taken  before  a  summary  court  and  for 
more  serious  offenses  they  go  before  a  general  or  special 
court-martial. 


ARMY  REGULATIONS  417 

ARTICLE  1.  Every  officer  now  in  the  Army  of  the  United 
States  shall  within  six  months  from  the  passing  of  this  act,  and 
every  officer  hereafter  appointed  shall  before  he  enters  upon  the 
duties  of  his  office,  subscribe  to  these  rules  and  articles. 

ARTICLE  2.  These  rules  and  articles  shall  be  read  to  every 
enlisted  man  at  the  time  of,  or  within  six  days  after,  his  enlist- 
ment, and  he  shall  thereupon  take  an  oath  or  affirmation,  in  the 
following-  form  : 

"I,  A.  B.,  do  solemnly  swear  (or  affirm)  that  I  will  bear  true 
faith  and  allegiance  to  the  United  States  of  America;  that  I  will 
serve  them  honestly  and  faithfully  against  all  their  enemies 
whomsoever,  and  that  I  will  obey  the  orders  of  the  President  of 
the  United  States  and  the  orders  of  the  officers  appointed  over 
me,  according  to  the  Rules  and  Articles  of  War." 

This  oath  may  be  taken  before  any  commissioned  offi- 
cer of  the  Army. 

ARTICLE  3.  Every  officer  who  knowingly  enlists  or  musters 
into  the  military  service  any  minor  over  the  age  of  sixteen  years 
without  the  written  consent  of  his  parents  or  guardian,  or  any 
minor  under  the  age  of  sixteen  years,  or  any  insane  or  intoxicated 
person,  or  any  deserter  from  the  military  or  naval  service  of  the 
United  States,  or  any  person  who  has  been  convicted  of  any  in- 
famous criminal  offense  shall,  upon  conviction,  be  dismissed  from 
the  service  or  suffer  such  other  punishment  as  a  court-martial 
may  direct. 

ARTICLE  4.  No  enlisted  man,  duly  sworn,  shall  be  discharged 
from  the  service  without  a  discharge  in  writing,  signed  by  a  field 
officer  of  the  regiment  to  which  he  belongs,  or  by  the  command- 
ing officer,  when  no  field  officer  is  present; 

Field  officers  are  officers  of  the  rank  of  major  or  above, 
and  that  is  a  distinction  one  will  frequently  come  across 
in  the  literature  which  will  be  read  in  regard  to  army  life. 

...  no  discharge  shall  be  given  to  an  enlisted  man  before  his 
term  of  service  has  expired  except  by  order  of  the  President,  the 
Secretary  of  War,  the  commanding  officer  of  a  department  or  by 
sentence  of  a  general  court-martial. 

It  is  understood  of  course  that  the  United  States  is  di- 
vided into  various  districts.  New  England  is  in  the 
Northeastern  District. 


41S  MILITARY  ADMINISTRATION 

ARTICLE  5.  Any  officer  who  knowingly  musters  as  :>  soldier 
a  person  who  is  not  a  soldier  shall  he  deemed  guilty  of  knowingly 
making  a  false  muster  and  shall  be  punished  accordingly. 

There  is  a  list  of  the  various  men  in  the  officer's  hands 
which  is  called  the  muster  roll.  Mustering  men  means 
simply  to  see  that  they  are  all  accounted  for,  that  they 
have  answered  their  names  at  roll  call.  The  purpose  of 
this  article  is  to  punish  a  man  who  puts  a  man's  name  on 
the  muster  roll  when  the  man  himself  is  not  present,  for 
the  purpose  of  trying  to  cover  up  cases  of  desertion,  etc. 

ARTICLE  6.  Any  officer  who  takes  money,  or  other  things, 
by  way  of  gratification,  on  mustering  any  regiment,  troop,  bat- 
tery, or  company,  or  on  signing  muster  rolls,  shall  be  dismissed 
from  the  service,  and  shall  thereby  be  disabled  to  hold  any  office 
or  employment  in  the  service  of  the  United  States. 

ARTICLE  7.  Every  officer  commanding  a  regiment,  and  in- 
dependent troop,  battery,  or  company,  or  a  garrison,  shall,  in  the 
beginning  of  every  month,  transmit  through  the  proper  channel, 
to  the  Department  of  War  an  exact  return  of  the  same,  specify- 
ing the  names  of  the  officers  then  absent  from  their  posts,  with 
the  reasons  for  and  the  time  of  their  absence.  And  any  officer 
who,  through  neglect  or  design,  omits  to  send  such  returns,  shall, 
on  conviction  thereof,  be  punished  as  a  court-martial  shall  direct. 

All  these  various  articles  represent  the  charges  which 
are  put  just  above  a  man's  name  in  conducting  the  court- 
martial.  If  he  has  violated  one  of  these  Articles,  that  is 
the  charge  brought  against  him. 

ARTICLE  8.  Every  officer  who  knowingly  makes  a  false  re- 
turn to  the  Department  of  War,  or  to  any  of  his  superior  offi- 
cers authorized  to  call  for  such  return,  of  the  state  of  the  regi- 
ment, troop  or  company,  or  garrison  under  his  command,  or  of 
the  arms,  ammunition,  clothing,  or  other  stores  thereunto  belong- 
ing, shall,  on  conviction  thereof  before  a  court-martial,  be  cash- 
iered. 

ARTICLE  9.  All  public  stores  taken  from  the  enemy  shall  be 
secured  for  the  service  of  the  United  States;  and  for  neglect 
thereof  the  commanding  officer  shall  be  answerable. 

ARTICLE  10.  Every  officer  commanding  a  troop,  battery,  or 
company,  is  charged  with  the  arms,  accouterments,  ammunition, 


ARMY  REGULATIONS  419 

clothing  or  other  military  stores  belonging  to  this  command,  and 
is  accountable  to  his  Colonel  in  case  of  their  being  lost,  spoiled, 
or  damaged  otherwise  than  by  unavoidable  accident,  or  on  actual 
service. 

ARTICLE  11.  Every  officer  commanding  a  regiment  or  an 
independent  troop,  battery,  or  company,  not  in  the  field,  may, 
when  actually  quartered  with  such  command,  grant  furloughs  to 
the  enlisted  men  in  such  numbers  and  for  such  time  as  he  shall 
deem  consistent  with  the  good  of  the  service.  Every  officer 
commanding  a  regiment,  or  an  independent  troop,  battery,  or 
company,  in  the  field,  may  grant  furloughs  not  exceeding  thirty 
days  at  one  time,  to  five  per  centum  of  the  enlisted  men  for  good 
conduct  in  the  line  of  duty,  but  subject  to  the  approval  of  the 
commander  of  the  forces  of  which  said  enlisted  men  form  a  part. 

Those  furloughs  are  given  to  men  particularly  for  good 
work. 

Every  company  officer  of  the  regiment,  commanding  any  troop, 
battery,  or  company  not  in  the  field,  or  commanding  in  any  gar- 
rison, fort,  post,  or  barrack,  may,  in  the  absence  of  his  field 
officer,  grant  furloughs  to  the  enlisted  men  for  a  time  not  ex- 
ceeding twenty  days  in  six  months,  and  not  to  more  than  two 
persons  to  be  absent  at  the  same  time. 

ARTICLE  21.  Any  officer  or  soldier  who,  on  any  pretense 
whatsoever,  strikes  his  superior  officer,  or  directs  or  lifts  up  any 
weapon,  or  offers  any  violence  against  him,  being  in  the  execu- 
tion of  his  office,  or  disputes  any  lawful  command  of  his  supe- 
rior officer,  shall  suffer  death,  or  such  other  punishment  as  a 
court-martial  may  direct. 

Article  twenty-one  is  very  commonly  used.     That  is 
one  that  dental  officers  will  most  have  to  watch. 

ARTICLE  22.  Any  officer  or  soldier  who  begins,  excites, 
causes,  or  joins  in  any  mutiny  or  sedition,  in  any  troop,  battery, 
company,  party,  post,  detachment,  or  guard,  shall  suffer  death 
or  such  other  punishment  as  a  court-martial  may  direct. 

ARTICLE  23.  Any  officer  or  soldier  who,  being  present  at 
any  mutiny  or  sedition,  does  not  use  his  utmost  endeavor  to  sup- 
press the  same,  or  having  knowledge  of  any  intended  mutiny  or 
sedition,  does  not  without  delay,  give  information  thereof  to  his 
commanding  officer,  shall  suffer  death,  or  such  other  punishment 
as  a  court-martial  may  direct. 


420  MILITARY  ADMINISTRATION 

ARTICLE  24.  All  officers,  of  what  condition  soever,  have 
power  to  part  and  quell  all  quarrels,  frays,  and  deserters, 
whether  among'  persons  belonging  to  his  own  or  to  another  corps, 
regiment,  troop,  battery,  or  company,  and  to  order  officers  into 
arrest,  and  non-commissioned  officers  and  soldiers  into  confine- 
ment, who  take  part  in  the  same,  until  their  proper  superior  offi- 
cer is  acquainted  therewith,  and  whosoever,  being  so  ordered, 
refuses  to  obey  such  officer  or  non-commissioned  officer  or  draws 
a  weapon  upon  him  shall  be  punished  as  a  court-martial  may 
direct. 

It  is  one  of  the  duties  of  an  officer  to  stop  any  fights, 
rebellions  or  anything  of  that  sort;  and  sometimes  one 
succeeds  with  this,  sometimes,  unfortunately,  not. 

ARTICLE  25.  No  officer  or  soldier  shall  use  any  reproachful 
or  provoking  speeches  or  gestures  to  another.  Any  officer  who  so 
offends  shall  be  put  in  arrest.  Any  soldier  who  so  offends  shall 
be  confined,  and  required  to  ask  pardon  of  the  party  offended,  in 
the  presence  of  his  commanding  officer. 

This  is  a  small  thing  apparently,  but  rather  common. 
All  these  various  Articles  of  War  are  written  to  maintain 
discipline. 

ARTICLE  26.  No  officer  or  soldier  shall  send  a  challenge  to 
another  officer  or  soldier  to  fight  a  duel,  or  accept  a  challenge 
so  sent.  Any  officer  who  so  offends  shall  be  dismissed  from  the 
service.  Any  soldier  who  so  offends  shall  suffer  such  punishment 
as  a  court-martial  may  direct. 

ARTICLE  27.  Any  officer  or  non-commissioned  officer  com- 
manding a  guard  who  knowingly  and  wilfully  suffers  any  person 
to  go  forth  to  fight  a  duel  shall  be  punished  as  a  challenger,  and 
all  seconds  or  promoters  of  duels  and  earners  of  challenges  to 
fight  duels  shall  be  deemed  principals  and  punished  accordingly. 
It  shall  be  the  duty  of  any  officer  commanding  an  army,  regiment, 
troop,  battery,  company,  post,  or  detachment,  who  knows  or  has 
reason  to  believe  that  a  challenge  has  been  given  or  accepted  by 
any  officer  or  enlisted  man  under  his  command,  immediately  to 
arrest  the  offender  and  bring  him  to  trial. 

ARTICLE  28.  Any  officer  or  soldier  who  upbraids  another 
officer  or  soldier  for  refusing  challenge,  shall  himself  be  punished 
as  a  challenger:  and  all  officers  and  soldiers  are  hereby  discharged 


ARMY  REGULATIONS  421 

from  any  disgrace  or  opinion  of  disadvantage  which  might  arise 
from  their  having  refused  to  accept  challenges,  as  they  will  only 
have  acted  in  obedience  to  the  law,  and  have  done  their  duty  as 
good  soldiers  who  subjected  themselves  to  discipline. 

ARTICLE  29.  Any  officer  who  thinks  himself  wronged  by  the 
commanding  officer  of  his  regiment,  and  who,  upon  due  applica- 
tion to  such  commander,  is  refused  redress,  may  complain  to  the 
general  commanding  in  the  state  or  territory  where  such  regiment 
is  stationed.  The  general  shall  examine  into  such  complaint  and 
take  proper  measures  for  redressing  the  wrong  complained  of; 
and  he  shall,  as  soon  as  possible,  transmit  to  the  Department 
of  War  a  true  statement  of  such  complaint  with  the  proceedings 
had  thereon. 

ARTICLE  30.  Any  soldier  who  thinks  himself  wronged  by 
any  officer  must  complain  to  the  commanding  officer  of  his  regi- 
ment, who  shall  summon  a  regimental  court-martial  for  the  doing 
of  justice  to  the  complainant.  Either  party  may  appeal  from 
such  regimental  court-martial  to  a  general  court-martial ;  but  if, 
upon  such  second  heating,  the  appeal  appears  to  be  groundless 
and  vexatious,  the  party  appealing  shall  be  punished  at  the  dis- 
cretion of  said  general  court-martial. 

ARTICLE  31.  Any  officer  or  soldier  who  lies  out  of  his 
quarters,  garrison,  or  camp,  without  leave  from  his  superior  offi- 
cer, shall  be  punished  as  a  court-martial  may  direct. 

The  above  is  another  common  Article  of  War.  It  means 
that  a  man  who  is  not  in  his  quarters  at  night  when  he 
should  be,  is  liable  to  punishment  according  to  the  Ar- 
ticles of  War. 

ARTICLE  32.  Any  soldier  who  absents  himself  from  his 
troop,  battery,  company,  or  detachment,  without  leave  from  his 
commanding  officer,  shall  be  punished  as  a  court-martial  may 
direct. 

ARTICLE  33.  Any  officer  or  soldier  who  fails,  except  when 
prevented  by  sickness  or  other  necessity,  to  report,  at  the  fixed 
time,  to  the  place  of  parade,  exercise,  or  other  rendezvous,  "ap- 
pointed by  his  commanding  officer,  or  goes  from  the  same,  with- 
out leave  from  his  commanding  officer,  before  he  is  dismissed 
or  relieved,  shall  be  punished  as  a  court-martial  may  direct. 

ARTICLE  3-1.  Any  soldier  who  is  found  one  mile  from  camp 
without  leave  in  writing  from  his  commanding  officer,  shall  be 
punished  as  a  court-martial  may  direct. 


422  MILITARY  ADMINISTRATION 

ARTICLE  35.  Any  soldier  who  f;iils  to  retire  to  his  quar- 
ters or  ten!  al  the  beating  of  retreal  shall  be  punished  according 
to  the  nature  of  his  offense. 

The  beating  of  retreat  is  the  last  call  before  taps  at 
night. 

The  above  articles  are  enough  to  give  one  an  idea  of 
the  Articles  of  War  and  how  they  apply  to  practically 
every  offense.  Unfortunately,  it  is  necessary  to  familiar- 
ize oneself  with  all  of  these,  because  one  is  liable  to  have 
to  prosecute  others.  Now  it  is  hopeless,  of  course,  to. 
expect  that  an  officer  is  going  to  know  absolutely  just 
what  his  duty  is  in  every  case.  There  are  a  thousand  and 
one  situations  and  circumstances  in  which  he  will  not 
know  exactly  what  to  do.  But  the  line  of  action  in  all 
these  matters  is  laid  down  in  the  Army  Regulations,  and, 
in  case  of  doubt,  if  possible  one  should  look  up  the  regu- 
lations. A  man  must  find  out  just  what  his  duty  is  every 
time. 

After  an  officer  is  commissioned  he  will  be  given  a  cer- 
tain set  of  books.  Among  these  books  are  the  Army 
Regulations.  These  must  be  read  intelligently.  It  is  a 
big  task,  but  one  must  look  to  the  "Bible"  and  see  what 
there  is  in  it  that  he  ought  to  know.  There  is  more  in 
it  than  it  is  possible  to  tell  of,  but  the  writer  hopes  to  give 
some  idea  of  it. 

All  persons  in  the  military  service  are  expected  to  obey 
promptly  all  lawful  orders  given  by  their  superiors. 
These  orders  should  be  carried  out  as  nearly  right  as 
possible.  Only  lawful  orders  are  obeyed.  When  a  soldier 
or  officer  gets  competent  orders,  if  they  are  competent  or- 
ders so  far  as  he  knows,  he  should  carry  them  out  and 
look  up  matters  of  doubt  as  to  their  competency  after- 
wards. 

Another  thing  which  is  very  useful  to  know  is  that  an 
officer  of  the  Medical  Department  can  exercise  command 
only  through  his  own  department,  but  as  a  staff  officer 
he  can  command  all  enlisted  men  as  his  officers  may  do. 


ARMY  REGULATIONS  423 

Traveling1.— There  is  some  red  tape  in  connection  with 
officers  traveling  while  on  duty.  If  a  person  is  traveling 
with  troops  the  transportation  will  be  cared  for.  If  trav- 
eling alone,  he  can  get  from  the  Quartermaster  a  trans- 
portation request.  If  traveling  on  a  mileage  basis,  he  will 
be  allowed  mileage  at  the  rate  of  seven  cents  per  mile. 

Adjutant.— Now  a  word  will  be  said  about  the  adju- 
tant. The  adjutant  is  a  very  good  fellow  to  know.  In 
fact,  he  is  generally  picked  out  because  he  is  a  student  of 
military  affairs,  is  a  good  fellow,  a  good  mixer  and  has  a 
good  deal  of  tact  and  knows  how  to  manage  things.  He 
always  acts  for  the  colonel  of  the  regiment.  All  routine 
business  is  done  through  him,  not  through  the  colonel. 
One  never  should  go  to  the  colonel  first  on  a  matter  of 
business,  but  to  the  adjutant,  if  one  has  any  business  to 
do  in  the  regiment.  The  adjutant  should  be  courteous 
and  on  friendly  terms  with  all.  He  must  show  a  great 
deal  of  discretion  and  be  well  informed  on  all  subjects 
connected  with  army  life.    He  is  a  very  useful  officer. 

Senior  Medical  Officer.— In  the  medical  department, 
when  one  first  enters  the  service,  he  should  frequently 
see  the  senior  medical  officer.  When  assigned  to  a  regi- 
ment, a  man  is  under  the  senior  officer  of  that  regiment, 
and  if  in  trouble  he  should  go  to  him. 

Honors.— Now  a  word  in  regard  to  honors.  This  is 
very  important,  because  it  must  be  observed  in  daily  life 
all  the  time.  One  acts  up  to  his  rank.  Rank  has  its 
privileges.  To  a  superior  a  certain  amount  of  deference 
is  shown  at  all  times,  and  inferiors  show  one  a  certain 
amount  of  deference  in  turn.  In  the  matter  of  saluting, 
a  junior  always  salutes  his  superior.  Among  men  hold- 
ing the  same  rank,  one  always  is  superior  or  junior  to 
the  other,  depending  on  how  long  each  officer  has  held 
his  rank.  If  both  men  had  received  their  present  com- 
missions on  the  same  date,  but  one  had  longer  previous 
service,  that  man  would  outrank  the  other.  One  must 
always  treat  officers  as  gentlemen.     It  is  a  question  of 


424  MILITARY  ADMINISTRATION 

civility.  A  person  is  independent,  but  lie  must  live  up  to 
certain  customs;  and  when  he  salutes  a  man,  it  should  be 
as  a  soldier,  not  slouchily. 

Etiquette  of  Dress.— There  is  often  nothing  said  in  or- 
ders as  to  what  a  man  shall  wear  on  different  occasions, 
but  there  is  a  little  book  which  may  be  obtained  which 
deals  particularly  with  dress.  This  book  tells  what  to 
wear  on  each  occasion.  Suppose  a  man  has  just  joined 
his  regiment  and  wishes  to  call  on  the  Colonel.  He  does 
not  know  what  the  customs  of  this  regiment  are,  but  he 
would  like  to  pay  his  respects  to  the  Colonel  as  soon  as 
possible.  What  uniform  should  he  wear!  He  goes  to 
the  adjutant  who  tells  the  new  officer  what  to  do ;  that  is 
his  business.  After  being  told  what  to  wear,  it  is  not 
well  to  call  on  the  Colonel  when  he  is  having  lunch  but 
during  office  hours.  In  several  cases  an  officer  reported 
for  duty  while  the  Colonel  was  at  lunch.  The  Colonel 
never  turned  round  an  inch  but  left  him  standing  there 
at  attention  while  he  finished  his  meal  at  his  leisure.  It 
does  not  take  long  to  teach  a  fellow  in  some  such  manner 
the  right  way  of  doing.  If  he  did  not  do  it  in  the  right 
way,  the  Colonel  would  contrive  some  way  to  impress 
the  proper  method  on  his  mind.  One  should  make  a 
social  call  on  the  Colonel  and  his  family.  The  Colonel 
will  probably  be  glad  enough  to  see  a  new  officer. 

Salute.— In  saluting  one  should  always  salute  like  a 
soldier,  standing  on  the  feet  squarely;  bringing  the  hand 
up  promptly ;  looking  serious  about  it ;  and  waiting  until 
the  hand  of  the  superior  comes  up.  The  instant  his  comes 
up  the  inferior's  goes  down.  An  officer  or  an  enlisted 
man  will  judge  a  man  by  the  manner  of  saluting  about  as 
quickly  as  in  any  way.  If  one  salutes  carelessly  an  opin- 
ion is  formed  right  away  of  what  kind  of  fellow  he  is.  Of 
course  he  may  learn  better  later.  When  a  man  is  not  on 
duty  he  greets  fellow  officers  as  gentlemen  in  civil  life 
would.  One  thing  to  remember  is  that  the  commanding 
officer  is  the  man  for  whom  one  is  working  and  one  is 


BLANKS  FOR  REPORTS  AND  RETURNS  425 

expected  to  do  everything  lie  can  to  help  him.  He  is 
not  doing  it  for  himself  or  to  help  his  record.  Many 
times  he  may  differ  from  his  superior.  The  sanitary  offi- 
cer must  inspect  the  camps  afterwards  if  errors  exist,  and 
they  usually  do;  he  goes  down  and  talks  about  it  with  the 
adjutant  first.  He  may  then  have  to  talk  with  the  com- 
manding officer  and  begin  to  criticize  his  camp,  but  very 
diplomatically,  and  he  will  always  meet  with  a  responsive 
spirit.  The  officer  must  be  just  as  polite  about  it  as  can 
be  and  very  careful  to  say  nothing  to  hurt  the  personal 
feelings  of  the  commanding  officer. 

It  is  better  not  to  write  letters  if  one  can  help  it.  They 
are  always  on  file  and  may  come  up  to  disturb  a  person 
later.  If  a  man  has  to  write  letters  he  should  put  in  them 
only  the  nicest  things  possible.  Any  communication 
to  a  superior  officer  is  sent  through  his  adjutant.  All 
letters  from  the  commanding  officer  conclude  "By  order 
of  the  Commanding  Officer,"  and  are  signed  by  the  adju- 
tant. 


THE  USE  OF  BLANKS  IN  THE  PREPARATION  OF 
REPORTS  AND  RETURNS 

The  subject  of  paper  work  in  the  Army  is  dry  and  yet 
very  important,  because  what  is  not  done  right  at  first 
must  be  done  over  later.  The  first  thing  to  do  is,  of 
course,  to  make  oneself  of  permanent  value  to  the  sendee. 
In  the  service  there  are  all  kinds  of  men:  courteous  gen- 
tlemen, roughs,  people  with  "swelled  heads,"  and  every 
sort  of  man  that  one  ordinarily  runs  across  in  civil  life. 
One  need  not  be  rebuffed  by  anybody.  Things  are  taken 
as  they  come.  The  Manual  of  the  Medical  Department 
and  the  Army  Regulations  are  the  only  authorities  to  con- 
trol a  person's  actions,  and  he  tries  to  follow  them  as 
closely  as  possible. 

Dental  Supplies. — The  first  thing  required  is  the  port- 


426  MILITARY  ADMINISTRATION 

able  dental  outfit,  so  called.  The  Manual  has  a  chapter 
on  dental  supplies,  which  is  indexed.  That  chapter  tells 
what  one  should  get ;  how  to  get  it ;  and,  generally,  where 
it  comes  from;  although  one  fault  of  the  book  is  that  it 
does  not  tell  from  whom  to  require  these  articles.  A  man 
is  pretty  safe  if  attached  to  an  organization,  as  he  can 
go  to  the  highest  medical  officer  in  the  organization.  Gen- 
erally a  dentist  will  be  in  some  division  of  troops,  and 
medical  officers  are  attached  to  every  kind  of  outfit. 
Whatever  the  division,  it  has  what  is  called  a  chief  sur- 
geon or  the  division  surgeon.  He  is  the  person,  then, 
under  those  circumstances,  to  whom  all  requisitions  are 
sent. 

Filling  Requisitions.— If  one  knows  what  forms  are 
used  for  these  things,  he  gets  out  a  field  desk  and  bor- 
rows the  first  blank  requisition  forms,  called  special 
requisition  for  supplies.  There  are  in  three  lines  the 
words  Post  Medical,  Field  Medical,  and  Dental.  The  two 
headings  that  do  not  apply  are  crossed  out.  At  the  top 
are  the  words  Annual,  Semi-annual,  Emergency.  If  one 
crosses  out  "Annual"  and  "Semi-annual"  and  leaves 
"Emergency,"  this  implies  Emergency  Special  Requisi- 
tion for  Dental  Supplies  Required.  Next  is  put  down  the 
place  of  writing,  the  name  of  the  regiment,  for  instance, 
Fifth  Regiment,  National  Guard  of  Massachusetts,  or 
whatever  outfit  one  happens  to  be  with.  A  man  may  not 
be  with  one  regiment ;  he  may  be  in  a  concentration  camp. 
He  is  chief  dental  officer  in  such  a  regiment  or  such  a 
concentration  camp,  and  he  puts  those  facts  down.  Then 
there  is  a  place  for  the  year,  if  the  requisition  is  annual ; 
for  the  quarter,  if  quarterly;  or  for  the  date,  if  emer- 
gency. This  is  fairly  self-explanatory,  if  it  is  read  with 
some  intelligence.  Forms  should  be  as  nearly  right  as 
possible;  otherwise,  they  will  be  sent  back.  The  space 
for  the  requisition  is  left  blank.  The  same  procedure  is 
adopted  on  the  front  of  the  form.  It  must  be  found  out 
from  the  adjutant  how  many  officers  and  enlisted  men  he 


BLANKS  FOR  REPORTS  AND  RETURNS  427 

has.  The  hospital  corps  man  goes  to  the  adjutant  to  find 
out  what  the  strength  of  the  command  is.  The  adjutant 
writes  back  "246  officers,  1,239  men,"  all  of  which  is  then 
entered  on  the  top  of  the  form. 

Portable  Outfit.— In  securing  the  portable  outfit  a  com- 
plete list  will  be  found  in  Chapter  854  of  the  Manual. 
This  covers  about  four  pages  and  gives  the  articles  re- 
quired. In  that  list  are  a  great  many  items.  The  requisi- 
tion for  a  Portable  Outfit  must  be  made  out.  The  neces- 
sity for  the  articles  required  is  set  forth  under  the  head- 
ing of  "Remarks."  A  statement  is  made  that  there  is 
no  outfit  and  that  one  is  required. 

Three  copies  are  needed :  one  to  be  kept  and  two  to  be 
forwarded.  All  these  requisitions  go  through  medical 
channels.  The  senior  medical  officer  asks  whether  or  not 
the  dental  officer  has  required  the  portable  outfit.  The 
requisition  is  sent  to  him.  He  takes  it,  looks  it  over,  and 
promptly  sends  the  requisition  to  the  brigade  surgeon, 
who  is  thus  notified  that  the  doctor  is  commencing 
work,  and  the  requisition  goes  along  to  the  division  sur- 
geon. The  division  surgeon  knows  where  the  portable 
outfits  are,  if  there  are  any  in  the  vicinity,  and  he  for- 
wards the  requisition  to  the  supply  depot,  wherever  it 
may  be. 

Blanks. — There  is  also  a  requisition  for  blank  forms. 
"When  a  man  first  goes  into  the  service,  he  will  have  no 
blanks  and  may  have  to  borrow  at  first.  On  a  requisition 
for  blank  forms  are  listed  all  the  blanks  that  an  officer 
will  have  to  have.  Of  course,  one  never  can  get  them  all, 
but  he  can  get  some  or  most  of  them.  This  is  sent  to 
the  Surgeon  General  at  Washington.  A  list  is  made  of 
the  forms  wanted  with  the  number  of  each  that  are  re- 
quired. In  the  first  part  are  spaces  for  Number  Used  in 
Past,  Number  on  Hand,  and  Number  Required.  In  a 
month  or  so  the  kinds  that  are  in  stock  are  sent. 

Receipt  of  Supplies.— "When  the  supplies  come,  they 
will  arrive  with  a  check  list,  which  is  an  ordinary  check 


428  MILITARY  ADMINISTRATION 

list  of  the  property  sent.  It  is  turned  over  to  an  assist- 
ant, who  will  open  the  cases  and  sort  the  goods  out.  At 
the  same  time  are  received  two  invoices  and  two  receipts 
by  mail  from  the  supply  depot  which  fills  the  requisition. 
The  invoices  are  signed  by  the  depot,  the  receipts  are  to 
be  signed  by  the  recipient.  The  property  that  comes  is 
checked  up.  A  man  must  be  sure  he  has  it  all  and  be  on 
the  alert  himself.  He  has  to  sign  for  it  and  is  responsible 
for  every  article. 

Items.— There  are  two  kinds  of  items,  expendable  and 
non-expendable.  It  is  easy  to  tell  whether  an  item  is 
expendable  or  not,  because  the  non-expendable  items  are 
in  italics.  Non-expendable  items  constitute  the  articles 
which  must  be  accounted  for,  if  lost  or  broken.  Expend- 
able items  are  not  in  italics,  and  when  used  up,  are  ac- 
counted for  in  reports  by  writing  opposite  the  item  Ex- 
pended. In  checking  up  non-expendable  articles  care 
must  be  used,  for  one  is  held  accountable  for  them.  A 
record  of  each  one  is  kept  separately,  a  monthly  inven- 
tory is  made,  and  the  account  is  straightened  out  twice  a 
year. 

Invoices.— On  the  invoices  and  receipts  which  accom- 
pany supplies  there  is  a  list  of  all  the  property  issued  to 
the  dentist  by  the  depot.  The  form  is  marked  Return  of 
Dental  Property  in  the  brief,  but  on  the  top  of  the  form 
it  is  called  Transfer  of  Dental  Supplies,  which  is  the 
more  proper  name.  It  is  a  form  which  can  be  used  for 
either  an  invoice  or  a  receipt  by  simply  crossing  out 
Invoice  in  one  case  or  Receipt  in  the  other.  The  man  at 
the  depot  will  cross  out  the  proper  word.  There  is  then 
a  voucher  or  a  receipt  for  dental  supplies  issued  or  re- 
ceived. 

Transferring  Property.— One  must  also  know  how  to 
transfer  property.  On  the  receipt  the  name  is  signed, 
rank  designated,  and  the  post  or  command  stated,  what- 
ever it  may  be.  All  vouchers  are  numbered  serially,  so 
that  they  can  be  referred  to  in  reports  as  Voucher  No.  1, 


BLANKS  FOR  REPORTS  AND  RETURNS  429 

Voucher  No.  2,  Voucher  No.  3,  and  so  on.  The  word 
"voucher"  means  nothing  but  a  list  of  the  goods  which 
are  sent.  The  first  lot  of  goods  will  be  accompanied  by 
Voucher  No.  1,  the  second  lot  by  Voucher  No.  2,  and  so 
on.  These  are  kept  together  by  means  of  an  elastic  band 
so  as  not  to  let  the  wind  blow  them  away. 

Listed  Outfit.— In  making  out  requisitions  every  article 
is  itemized.  Fortunately,  there  is  a  printed  list.  In  the 
first  part  of  the  list  under  Portable  Outfit  are  found: 
phenol,  sodii  carbonas  monohydratus,  etc.;  under  Sta- 
tionery, eraser,  examination  blanks,  ruler,  etc.;  under 
Books,  Dental  Materia  Medica,  Therapeutics  and  Pre- 
scription Writing,  Dental  Pathology,  Therapeutics  and 
Pharmacology  (Burchard),  Dentistry  First  Aid  (Ryan), 
Handbook  for  the  Hospital  Corps,  Oral  Surgery  (Bro- 
phy).  Those  books  will  come  in  the  field  desk,  which  is 
part  of  the  outfit.  Then  there  is  a  long  list  of  Instru- 
ments and  Appliances.  In  this  are  found :  oak  office 
case,  for  preparations ;  18^-ounce  glass-stopper  bottles ; 
corkscrews;  dental  engine  with  No.  2  slip-joint  attach- 
ment; cables,  etc.  The  furniture  consists  of  a  dental 
chair,  which  goes  into  a  chest,  and  there  is  also  a  chest 
for  dental  engines,  a  special  chest,  an  instrument  chest 
for  extractors,  etc ;  a  field  desk ;  portable  stands ;  a  table, 
and  a  lot  of  miscellaneous  material. 

Now  when  a  man  has  his  property,  he  is  supposed  to 
receipt  for  it  within  thirty  days  or  he  is  held  responsible 
for  it.  Another  thing  should  be  noted.  If  property  is 
invoiced  to  a  man  and  he  fails  to  receive  it,  he  is  still  held 
responsible  for  that  property.  So  if  the  property  does 
not  come  he  cannot  sit  down  and  wait  for  it,  but  must 
find  out  where  it  is.  It  may  have  been  smashed  up.  He 
is  responsible  for  it  as  soon  as  it  leaves  the  depot,  and  it 
is  his  business  to  hunt  for  it.  When  one  gets  the  in- 
voices and  receipts,  and  the  property  as  shown  on  them, 
he  signs  the  receipts.  The  invoices  are  already  signed. 
The  two  invoices  are  held  until  the  semi-annual  return  is 


430  MILITARY  ADMINISTRATION 

scut.  One  of  those  invoices  is  forwarded  with  the  semi- 
annual return  to  the  Surgeon  General,  showing  that  one 
actually  received  the  property.  One  of  the  receipts  is 
sent  to  the  depot  or  officer  from  whom  the  supplies  came, 
and  the  other  is  sent  to  the  Surgeon  General.  When  this 
property  is  received  one  must  not  depend  entirely  on  the 
invoices  to  keep  an  account  of  them,  but  the  hospital 
corps  man  can  keep  a  list,  so  that  an  officer  has  his  list  as 
well  as  the  invoices,  and  if  one  of  them  goes  astray  there 
is  the  other.  It  is  very  important  to  pay  a  good  deal  of 
attention  to  the  hospital  corps  man  assigned  as  dentist's 
assistant.  He  must  be  made  to  do  things  right  at  first  be- 
cause after  a  while  he  is  going  to  run  the  office.  That  hos- 
pital corps  man  must  be  carefully  handled  and  must  be 
carefully  trained  and  made  responsible. 

Returns. — After  having  checked  up  the  property  and 
having  seen  that  one  has  everything  that  belongs  to  him 
and  having  signed  the  receipts,  he  is  ready  to  go  to  work. 
A  return  is  made  to  the  Surgeon  General  annually  or 
semi-annually,  as  the  case  may  be,  of  every  article  of 
property  that  one  possesses.  The  hospital  corps  man 
may  do  this  or  one  may  do  it  oneself  if  he  desires.  It  is  a 
good  idea  to  do  it  oneself.  The  return  is  sent  in  on  a 
folder,  which  bears  on  the  outside  cover  Return  of  Med- 
ical Property.  Inside  are  a  lot  of  instructions  which 
must  be  very  faithfully  followed.  Officers  include  in  their 
medical  property  returns  all  property  of  the  Medical 
Department  which  comes  into  their  possession,  except  as 
otherwise  expressly  provided  for  in  the  regulations. 
Generally  it  is  comparatively  safe  to  put  it  all  in.  All 
property  that  comes  into  one's  possession,  no  matter  how, 
is  put  down.  If  one  finds  he  has  more  property  than 
he  is  charged  with,  he  notes  that  fact  down  in  the  re- 
turns, because  that  is  the  property  of  somebody  else  who 
will  have  to  answer  for  its  loss  and  return  of  such  excess 
may  clear  his  account. 

Each  of  these  forms  has  its  number.    Most  men  in  the 


BLANKS  FOR  REPORTS  AND  RETURNS  431 

service  can  tell  the  form  number  immediately.  One  asks 
for  Form  22,  or  whatever  the  number  may  be.  These 
property  returns  are  sent  in  on  Form  17.  The  back  cover 
is  called  17  c;  the  so-called  "original  return"  is  called 
17a;  and  the  so-called  "retained  return,"  17b.  The  de- 
partment does  not  bind  these  together;  it  leaves  that  to 
the  officer.  When  the  form  is  completed,  the  back  cover 
goes  down  first;  the  blue  sheet,  17b,  goes  next  to  that,  the 
white  sheet,  17a,  next  to  that,  and  then  the  top  cover  is 
laid  over  the  whole  thing,  binding  it  together  through  the 
perforated  holes.  If  one  has  but  one  item,  he  must  enter 
it  both  on  a  white  and  a  blue  form,  making  the  blue  form 
with  carbon  paper.  On  the  returns  the  different  voucher 
numbers  are  entered  for  goods  that  have  been  received, 
that  is,  one's  own  voucher  numbers  and  not  anybody 
else's.  Opposite  the  expendable  articles  which  have  been 
used,  one  simply  writes  in  Are  expended.  In  the  case  of 
these  articles  an  officer  generally  waits  until  the  end  of 
the  year  and  then  expends  them  at  one  time.  There  is 
nothing  to  stop  him  from  doing  that.  That  is  generally 
the  way  it  is  done,  only  it  is  not  wise  to  expend  too  much 
or  there  will  be  an  inquiry.  The  department  does  check 
up  the  items  but  generally  one  does  not  bother  with  ex- 
pendable articles.  In  the  returns  one  enters  as  expended 
what  he  thinks  he  has  expended,  but  it  is  well  not  to  let 
one's  imagination  go  too  far.  It  is  well  to  take  an  inven- 
tory of  property  occasionally.  The  blue  sheets  are  re- 
tained between  the  covers  for  one's  own  files  and  the 
white  sheets  are  forwarded  to  the  Surgeon  General  semi- 
annually or  annually  as  required.  If  there  are  any  dis- 
crepancies, one  will  be  asked  to  account  for  them. 

There  is  also  an  annual  requisition  for  dental  supplies. 
This  is  not  used  in  the  field.  In  the  field  there  is  never 
any  chance  to  use  it.  Only  emergency  requisitions  are  in 
use  in  the  field,  and  these  are  practically  the  same  as  the 
invoice. 

Appointment  Form.  — Next  there  is  Form  65,  which  is 


432  MILITARY  ADMINISTRATION 

an  appointment  form  for  a  dental  engagement.  It  is 
necessary  to  have  thousands  of  them.  It  is  a  little  blank 
form  in  which  one  puts  the  station  and  the  date,  and 
contains  the  following  invitation: 

It  is  requested  that  ,  of company,  report  to  the 

dentist  for  examination  at  o'clock. 

Suppose  one  does  not  finish  with  a  man  in  the  given 
hour,  and  must  carry  him  over  to  continue  the  treatment, 
he  then  applies  to  the  adjutant  of  the  regiment  on  the 
form  provided  for  the  purpose  to  have  the  man  come 
again,  giving  him  the  date  and  the  hour  that  he  must 
return  for  treatment.  Of  course  the  dental  officer  retains 
copies  so  that  he  will  know  when  the  men  are  to  report. 
Dentists  work  in  the  army  pretty  much  as  they  do  in 
civil  life.  They  start  in  about  8  o'clock  and  work  until 
lunch  time  and  come  back  and  work  in  the  afternoon.  If 
men  were  applying  for  appointments  practically  all  the 
time,  the  dentists  would  give  as  much  time  as  possible  to 
satisfy  the  demands  of  the  men.  When  work  slacked  up, 
they  would  take  an  afternoon  off.  The  appointment  form 
is  self-explanatory,  although  the  request  is  never  an- 
swered in  writing.  The  adjutant  simply  sends  the  men. 
If  they  do  not  appear  on  time  the  dentist  writes  to  the 
adjutant  saying  that  such  and  such  men  did  not  appear 
as  requested.  It  is  the  dentist's  business  to  check  the 
men  up.  If  he  did  not,  some  man  would  soon  be  saying, 
"I  know  a  soft  way  to  get  away  and  go  down  town  Tues- 
day, Thursday  and  Saturday  afternoons.  Simply  get  an 
appointment  with  the  dentist."  There  is  nobody  to  check 
these  men  but  the  dental  officer,  and  if  they  do  not  report, 
it  is  his  business  to  check  them  up.  The  adjutant  is 
informed  that  in  response  to  the  invitation  the  man  did 
not  appear.  The  dentist  makes  the  request,  and  the  adju- 
tant directs  the  man  to  return  and  report.  The  word 
"direct"  means  a  command.  As  a  rule,  the  adjutant  will 
back  the  dentist  up  in  holding  the  men  strictly  to  their 


BLANKS  FOR  REPORTS  AND  RETURNS  433 

appointments.  When  the  patient  arrives  one  must  keep 
a  register  of  the  work  done  for  him,  and  that  register  is 
called  a  register  card.  There  is  a  register  card  in  the 
medical  department.  The  dental  card  is  a  little  different. 
Dental  Cards.— The  Manual  devotes  a  chapter  to  the 
registry  of  patients.    In  this  it  is  stated : 

465.  A  register  of  dental  patients  will  be  kept  on  cards, 
Form  79,  at  every  post  or  station  attended  by  a  member  of  the 
Dental  Corps. 

466.  The  ease  of  every  officer  and  enlisted  man  of  the  Army 
who  is  treated  by  the  dentist  will  be  entered  in  the  register,  a 
separate  card  being  made  for  each  period  of  continuous  treat- 
ment. Upon  the  conclusion  of  continuous  treatment  in  any  case 
its  card  will  be  closed  by  appropriate  entry  in  the  "Results" 
column. 

Should  it  become  necessary  to  discontinue  the  work  on  a  case 
on  account  of  the  dentist's  departure  from  the  station  the  case 
will  be  closed  on  the  card,  making  a  record  of  the  status  of  the 
work  in  the  "Results"  column. 

The  cards  are  kept  in  two  separate  files,  the  current 
file  and  the  permanent  file.  The  current  file  contains  a 
record  of  uncompleted  cases  and  cards  are  transferred 
from  the  current  file  to  the  permanent  file  immediately- 
after  their  completion.  The  cards  should  be  legibly  writ- 
ten in  black  ink  with  pen  or  typewriter  as  may  be  most 
convenient.  If  the  entry  must  be  extended  to  the  other 
side,  a  mark  in  parentheses  (a)  is  placed  and  the  card  is 
turned  over  on  the  back ;  (a)  is  then  written  and  the  entry 
continued  across  the  back  of  the  card.  This  must  be  done 
very  carefully.  If  one  cannot  get  a  complete  remark  in 
these  columns,  it  is  necessary  to  take  plenty  of  room,  to 
go  as  far  as  possible  and  then  turn  it  over,  prefixing  with 
(a),  (b),  etc.,  and  continuing  the  remarks. 

Signing. — The  dentist  shall  sign  or  initial  all  dental 
cards.  That  means  just  what  it  says.  One  must  sign 
his  name  for  every  man  treated.  If  not,  the  cards  will 
all  come  back  for  correction.  Alterations  must  be  au- 
thenticated by  the  dentist's  initials.     If  the  typewriter 


434  MILITARY  ADMINISTRATION 

hits  the  letter  a,  instead  of  the  letter  s,  the  change  must 
be  authenticated  by  initials.  If  a  letter  is  rubbed  out, 
it  must  be  authenticated  with  the  dentist's  initials.  Thus 
every  change  must  be  authenticated.  The  writer  has  had 
dozens  of  cards  come  back  where  the  clerk  had  struck 
letters  over,  and  has  been  asked  to  authenticate  the 
changes,  and  he  had  to  go  over  them  and  sign  his  name 
to  every  one  of  them,  though  the  cards  had  been  away 
perhaps  for  a  month. 

In  making  out  the  cards  the  patient's  surname  and 
Christian  name  are  used.  No  middle  name  is  written 
out;  simply  the  initial  is  used.  Otherwise  the  card  will 
come  back.  The  rank  of  each  man,  whether  private,  cor- 
poral or  sergeant,  or  whatever  it  may  be,  is  put  in  ami 
entered  under  the  word  Rank.  One  must  find  out  the 
company  he  comes  from,  what  regiment  or  staff  corps  he 
belongs  to,  and  enter  that;  the  man's  age  is  entered,  and 
in  writing  ages  the  number  of  months  is  usually  indi- 
cated in  the  form  of  a  fraction,  thus :  22  11/12  years;  his 
race  is  stated,  whether  white,  black,  yellow  or  brown; 
also  where  he  was  born  and  the  number  of  years  he  has 
been  in  the  service.  All  this  is  necessary  to  identify  the 
man.  At  the  bottom  is  the  signature  of  the  dental  sur- 
geon. "When  an  officer  or  soldier  comes  who  has  been 
previously  on  the  register,  a  new  card  will  be  made  for 
the  new  course  of  treatment.  This  card  is  used  only  to 
carry  the  patient  through  the  time  the  dentist  is  working 
on  his  teeth.  When  the  treatment  is  finished  that  card  is 
closed  and  transferred  from  the  current  file  to  the  per- 
manent file.  At  the  end  of  each  month  a  return  is  made 
so  that  the  Government  may  know  what  has  been  done. 
It  may  be  that  a  dentist  is  treating  cases  from  his  own 
regiment  or  from  several  regiments.  In  that  case  he 
may  enter  in  his  monthly  report  his  own  regiment  and 
all  detachments  from  which  cases  have  come.  All  in- 
structions should  be  read  very  carefully  and  carefully 
followed.    If  the  form  has  been  filled  out  improperly  it 


BLANKS  FOR  REPORTS  AND  RETURNS  435 

will  have  to  be  clone  over.  A  record  of  the  dental  work 
required  is  made  on  such  a  form.  It  will  be  made  and 
signed  by  the  dentist.  If  no  patients  have  been  treated 
during  the  month,  the  report  is  made  No  patients  for 
treatment,  or,  No  treatment  was  given  at  this  station. 
The  report  is  then  forwarded  through  medical  channels 
to  the  brigade  surgeon,  then  to  the  department  surgeon, 
thence  to  the  surgeon  general,  and  eventually  is  sent  back. 
The  dentist  must  make  out  his  report  before  the  fifth 
day  of  the  next  succeeding  month.  If  he  does  not,  one 
of  the  chief  surgeon's  clerks  will  ask  for  the  monthly 
return  and  ask  to  have  it  sent  immediately.  The  chances 
are  that  the  dentist  was  too  busy  to  make  it  out  or  had 
forgotten  it.  But  that  fact  cannot  be  stated  in  the  return 
to  the  chief  surgeon. 

Contagious  Disease.— It  is  necessary  to  be  on  the  watch 
for  signs  of  contagious  disease.  This  is  very  important. 
The  medical  department  often  depends  on  the  dentists 
when  contagious  diseases  are  coming  up.  Many  diseases 
show  themselves  in  the  mouth  first.  Diagnoses  of  syph- 
ilis are  made  oftener  by  dentists  than  by  any  other  men 
through  the  discovery  of  mucous  patches  in  the  mouth. 
The  dentist  should  always  be  on  the  lookout  for  mucous 
patches.  There  may  be  mighty  little  syphilis  in  camp 
for  a  time  and  then  there  will  be  a  few  cases  cropping  up 
and  those  cases  will  get  in  before  one  has  any  idea  where 
they  came  from.  The  writer  had  a  cook  sent  him  once — 
one  of  the  greatest  difficulties  was  in  getting  good  cook- 
ing. The  division  surgeon  was  kept  hunting  all  the  time 
for  a  cook.  Of  course  a  lot  of  men  get  through  and  some 
come  in  with  an  efficiency  record  as  a  cook ;  that  is,  they 
were  cooks  in  civil  life,  and  may  also  have  attended  a 
school  of  instruction.  This  man  came  with  an  efficiency 
record.  It  was  found  later  that  he  had  been  a  waiter  on 
one  of  the  Fall  River  steamers.  Two  days  after  he  came 
he  had  a  little  cold  and  he  went  to  the  doctor  for  treat- 
ment.   The  doctor  happened  to  be  a  specialist  on  the  nose 


436  MILITARY  ADMINISTRATION 

and  throat.  On  asking  the  man  to  open  his  mouth  he 
saw  a  lot  of  mucous  patches.  The  doctor  was  a  hawk 
on  mucous  patches,  so  lie  took  that  man  out  of  the  cook 
house.  Tie  would  have  been  doing  the  cooking  had  he  not 
had  a  little  cold  and  gone  to  the  doctor  to  be  examined. 
These  things  must  be  watched  for.  Bakers  bake  for  the 
entire  command  and  do  wonderful  work.  The  dentist 
must  keep  his  eye  on  the  bakers.  He  is  the  only  man  to 
check  them  up.  At  night  they  will  get  to  town  if  they  can 
and  mucous  patches  must  be  watched  for.  When  a  case 
is  of  sufficient  importance,  a  special  report  on  it  is  made. 
The  report  should  be  written  in  black  ink  with  a  mod- 
erately coarse  pen  or  typewriter.  A  duplicate  of  the 
report  will  be  kept  on  file. 


FIELD    SERVICE    REGULATIONS 

Another  book  of  interest  to  the  army  officer  is  Field 
Service  Regulations.  It  contains  facts  and  directions 
about  field  service  and  about  actual  warfare.  Although 
it  is  concise,  everything  in  it  is  of  the  greatest  value  for 
every  soldier  to  know.  If  a  man  is  going  to  take  part  in 
the  game,  to  be  one  of  the  cogs  in  the  machine,  he  must 
know  all  about  it.  Although  this  is  not  perhaps  so  neces- 
sary to  dental  surgeons,  it  is  a  mighty  good  book  to  read. 
In  it  is  everything  connected  with  warfare  in  the  field, 
very  concisely  stated.  To  army  dentists,  as  members  of 
the  Sanitary  Service,  the  most  interesting  is  the  little 
chapter  in  this  book  relating  to  that  service.  This  will 
be  considered  now  in  brief. 

In  the  first  place  it  is  realized  that  every  sick  man,  or 
a  man  with  any  disability,  must  be  cared  for;  and  the 
care  of  that  man  requires  the  attention  of  other  men 
whose  ability  and  work  might  be  used  to  better  advan- 
tage in  helping  the  fighting  forces  in  the  field.  So  in  the 
beginning  when  men  are  examined,  those  men  who  are 


FIELD  SERVICE  REGULATIONS  437 

disabled  and  who  may  be  disabled  are  eliminated.  For 
that  very  reason  dentists  now  are  becoming  part  of  this 
great  force  to  enable  the  army  to  have  those  men  fit.  In 
the  field  a  man  cannot  pick  ont  his  food,  and  men  need 
teeth ;  if  they  are  going  to  be  disabled  through  digestive 
disturbances  they  are  going  to  be  a  handicap  to  the 
forces 

One  must  realize  in  the  fighting  forces  in  the  field  that 
everything  is  mapped  out  and  radiates  from  a  central 
point,  the  base;  that  merely  means  where  the  cam- 
paign is  being  conducted  from.  Branching  out  from  that 
are  various  lines  called  Lines  of  Communication,  and  the 
extremities  of  the  line  are  fighting  forces.  Now  there 
are  various  places  on  that  line  of  communication  that 
must  be  considered.  In  regard  to  the  fighting  forces,  it 
is  immaterial  what  they  are  doing;  whether  they  are  in 
the  trenches  or  in  open  country,  advancing  or  retreating, 
they  have  got  to  be  cared  for.  Everyone  knows  the  ex- 
pression "An  army  travels  on  its  belly."  The  men  must 
live,  and  live  well,  and  be  physically  as  nearly  perfect  as 
they  can  be  made.  There  are  also  their  arms  and  accou- 
trements; that,  however,  is  a  matter  that  does  not  concern 
dentists  much.  The  matter  that  most  interests  them  is 
the  line  of  Sanitary  Service. 

Tempoeaey  Caee  and  Peo visional  Teeatment  of  Sick 
and  Wounded 

Firing"  Line.— In  the  firing  line  each  regiment  or  com- 
pany has  with  it  a  certain  amount  of  sanitary  personnel ; 
if  an  infantry  regiment,  it  has  about  forty  hospital  corps 
men  and  four  surgeons,  and  two  dental  surgeons.  Now 
what  do  these  men  do  on  the  firing  line?  Their  business 
on  the  firing  line  is  simply  to  get  the  wounded  under  cover 
and  give  them  first-aid  treatment.  The  present  method  of 
caring  for  wounds  is  very  efficient,  and  until  newer  meth- 
ods are  installed,  will  be  retained.    No  extensive  opera- 


438  MILITARY  ADMINISTRATION 

tions  are  done  on  the  firing  line.  A  fractured  jaw  is 
simply  supported  and  held  in  place  with  the  bandage  in 
the  first-aid  package;  this  is  a  strip  of  roller  bandage 
gauze  about  five  feet  long,  in  the  center  of  which  is  sewed 
a  pad  of  gauze.  That  bandage  is  rolled  up  and  enclosed 
in  paraffin  paper ;  in  fact,  two  of  those  bandages  are  worn 
by  each  man ;  and  in  the  package  as  well  are  safety  pins 
and  printed  directions  how  to  use  it.  Both  these  ban- 
dages are  enclosed  in  a  thin  metallic  container  and  it  fits 
in  a  pocket  in  the  belt.  Every  officer  and  enlisted  man 
carries  that  first-aid  packet ;  and  in  only  a  few  years  that 
first-aid  packet  has  almost  taken  precedence  over  the 
revolver  or  ammunition.  Each  man  must  always  have 
his  first-aid  packet.  If  a  man  can  get  a  first-aid  dress- 
ing on  his  wounds  it  will  often  save  his  life.  The  man  is 
taught  how  to  use  it ;  he  is  supposed  to  apply  it  himself, 
or  a  neighbor  on  his  left  or  right  will  apply  it.  There 
is  no  waste  of  hospital  men  going  into  No  Man's  Land 
and  putting  on  dressings.  Everyone  knows  that  the  great 
mortality  among  medical  men  has  been  due  more  to  ab- 
solute carelessness  than  to  any  other  cause.  Men  lose 
their  reason  on  account  of  their  sympathy  and  send  doc- 
tors into  a  fire-swept  zone  to  bring  in  wounded.  Now  one 
must  be  hard-hearted  enough  to  leave  those  wounded  men 
until  night  comes  or  until  the  firing  slackens.  It  is  well 
enough  then  to  have  hospital  men  and  medical  officers 
where  they  can  give  all  the  treatment  they  may  in  the 
circumstances  where  the  men  are  found ;  it  is  well  enough 
to  give  them  all  the  medical  assistance  one  can ;  the  men 
need  that  assurance  to  keep  their  morale.  The  dressing 
station  is  established  as  close  to  the  firing  line  as  is  con- 
sistent with  comparative  safety  from  the  fire;  at  best 
from  rifle  and  machine  gun  fire  and,  of  course,  from  heavy 
artillery  fire.  At  the  firing  line,  then,  there  is  this  regi- 
mental aid ;  then  another  zone  of  medical  assistance  is  im- 
mediately in  the  rear,  covered  by  the  ambulance  corps. 
Ambulance  Line.— It  does  not  make  any  difference 


FIELD  SERVICE  REGULATIONS  439 

what  the  shelter  is, — a  swale  in  the  ground  behind  some 
rocks,  any  shelter  where  one  can  collect  and  bring  the 
wounded ;  and  this  is  often  a  hard  job.  It  is  a  well-known 
fact  that  about  nineteen  out  of  twenty  shots  go  over  the 
top  of  the  firing  line.  For  that  reason  immediately  in  the 
rear  is  a  poor  place  to  be,  and  it  is  difficult  many  times  to 
find  shelters  for  the  wounded;  but  one  does  the  best  he 
can. 

Xow,  as  has  been  said,  the  ambulance  corps  is  the  sec- 
ond zone  of  medical  attendance.  It  is  composed  of  a  num- 
ber of  ambulances,  litter  bearers,  and  a  dressing  station. 
The  first  party  to  go  out  is  the  litter  bearer  section.  It 
goes  out  from  the  rear  and  comes  in  contact  with  the  regi- 
mental aid  station.  If  in  the  rear  of  the  firing  line  the 
commanding  officer  of  the  Ambulance  Company  finds  a 
place  sufficiently  sheltered  to  care  for  these  wounded  men 
in  temporary  shelter,  he  establishes  a  dressing  station ; 
his  little  pack  mules  come  up  with  the  necessary  equip- 
ment. There  he  adjusts  the  dressings  that  have  been 
put  on  by  the  regimental  party  and  stops  unnecessary 
bleeding;  but  there  he  does  no  surgery  that  he  can  avoid. 
There  he  collects  the  wounded  until  later  he  gets 
an  order  to  transmit  them  to  the  field  hospital.  In  his 
dressing  station  he  does  whatever  emergency  surgery  he 
must  do  and  gives  the  wounded  hot  soup,  etc.,  to  get  them 
into  shape  to  be  transferred  to  the  field  hospital. 

Field  Hospitals. — Next  comes  the  third  line  of  medical 
assistance,  the  field  hospitals.  These  are  established  out- 
side the  zone  of  firing,  in  the  nearest  place  where  surgeons 
may  with  a  reasonable  degree  of  coolness  and  comfort  do 
major  surgery  and  do  it  well.  One  cannot  do  such  sur- 
gery while  shells  are  exploding  around  the  hospital.  So 
the  field  hospitals  are  established  outside  the  zone  of  ar- 
tillery fire  and  as  close  to  the  front  as  they  can  be  safely 
placed.  There  one  does  such  major  operations  as  are 
necessary.  There  the  wounded  are  held  temporarily 
until  they  are  tabulated. 


440  MILITARY  ADMINISTRATION 

Evacuation  Hospitals.— Then  there  is  another  line  of 
sanitary  service  which  consists  of  evacuation  hospitals. 
They  are  on  the  line  of  a  railroad  if  there  is  one,  or  on 
the  line  of  a  river.  These  naturally  are  larger  than  the 
field  hospitals,  but  are  of  practically  the  same  type  and 
equipment. 

At  the  base  there  is  another  system  of  hospitals  called 
base  hospitals,  where  those  men  who  are  going  to  get  well 
are  held  and  when  entirely  recovered  are  sent  back  to  the 
trenches;  but  from  the  base  those  who  are  injured  per- 
manently are  sent  to  their  homes  or  hospitals  near  their 
homes  as  soon  as  it  is  safe  to  move  them. 

At  any  of  these  places  the  dental  surgeon  may  be  as- 
signed to  assist;  it  is  reasonable  that  he  should.  His 
work  in  the  future  will  not  be  so  much  filling  the  teeth, 
but  repairing  these  face  and  head  wounds.  Shots  are 
mostly  in  the  head  and  face.  For  that  reason  the  dental 
surgeon  is  going  to  be  of  the  greatest  assistance. 

Sanitary  Equipment.— One  of  the  other  services  of  the 
sanitary  department  is  the  supply  of  sanitary  equipment. 
This  means  that  not  only  must  the  army  enlist,  equip, 
train  and  send  to  the  front  hospital  corps  men,  but  that  it 
also  must  obtain  and  send  forward  the  necessary  medical, 
surgical  and  sanitary  supplies  that  are  constantly  needed. 

Pensions. — Another  thing  to  remember  all  the  time  is 
that  in  many  instances  the  dental  officer  is  going  to  be  the 
one  man  who  decides  whether  a  disabled  soldier  receives 
a  pension  or  not.  As  a  basis  for  every  claim  is  this  ques- 
tion: "Was  this  wound  received  in  line  of  duty?"  and 
one  must  state  on  each  register  card  that  goes  through 
his  hands  whether  the  wound  was  received  in  line  of 
duty  or  not.  The  dentist  must  generally  judge  by  what 
he  sees  of  the  wound.  One  is  apt  always  to  err  in 
favor  of  the  man;  and  "in  line  of  duty"  not  only  means 
that  he  was  hurt  in  active  duty  but  even  perhaps  in  play- 
ing a  baseball  game.  When  it  is  not  in  line  of  duty  is 
when  it  was  received  in  a  manner  not  proper.    Many  men 


FIELD  SERVICE  REGULATIONS  441 

receive  sicknesses  from  things  which  they  have  done 
which  they  should  not  have  done ;  indiscretion  is  the  word 
that  perhaps  covers  it.  That  is  not  in  line  of  duty,  but 
in  all  other  things  one  can  err  in  favor  of  the  man.  That 
is  a  proper  thing,  even  though  it  is  in  playing  ball  or 
stealing  a  ride  on  the  railroad  train. 


ic> 


General  Sanitation 

Now,  again,  members  of  the  Medical  Department  are 
all  disciples  of  sanitation.  Everyone  must  realize  the  im- 
portance of  the  most  perfect  sanitation  where  men  are 
living  together  in  such  close  community  as  in  a  soldier's 
life.  One  reads  in  the  newspapers  now  of  the  ravages 
of  disease  among  these  men.  There  has  been  much  said 
lately  about  conditions  at  Commonwealth  Pier  and  at 
Newport.  We  are  constantly  hearing  about  conditions  at 
camps,  where  men  are  attacked  by  some  transmissible  dis- 
eases, and  it  is  no  small  task  to  stop  these  diseases.  For 
this  reason,  as  was  suggested  earlier,  one  must  be  on  the 
lookout  all  the  time  for  transmissible  diseases,  and  if  any 
question  at  all  comes  up  the  case  must  be  reported.  A 
man's  duty  is  done  when  he  reports  it.  This  came  home 
to  the  writer  in  recent  experiences  in  Texas,  on  the  bor- 
der. The  camp  was  in  an  area  filled  with  typhus  fever, 
with  typhoid  fever,  with  dysentery,  and  with  syphilis. 

Contagion  in  Camp.— Among  the  Mexicans  in  that 
region  every  other  person  has  syphilis.  Typhus  wipes 
out  whole  communities,  though  it  is  transmissible  only  by 
the  body  louse.  As  fast  as  one  of  these  cases  appeared 
in  the  hospital  the  doctors  flew  at  it  like  dogs  and  stuck 
to  that  case  and  took  all  the  precautions  they  could  to 
stop  the  spread  of  it.  A  case  of  amebic  dysentery  per- 
haps appeared  in  camp;  the  man  had  a  little  diarrhea 
and  was  not  able  to  do  his  duty,  just  as  with  any  other 
dysentery.  Unless  his  stools  were  examined  for  the 
aniebas,  one  might  never  know  that  he  had  amebic  dysen- 


44l>  MILITARY  ADMINISTRATION 

tery,  until  through  tlie  medium  of  the  patient's  excreta, 
through  Hies,  and  through  the  doctor's  sins  of  omission, 
a  general  infection  of  the  camp  had  occurred.  In  that 
region  one  could  open  a  lunch  box  about  five  miles  away 
from  any  habitation,  even  a  mile  in  the  air  on  top  of  Mt. 
Franklin,  where  there  is  not  a  particle  of  moisture,  and 
in  ten  minutes  that  box  would  be  covered  with  flies ;  and 
flies  are  the  greatest  transmitters  of  intestinal  diseases, 
practically  the  only  source.  One  must  all  the  time  be  on 
the  wratch  for  these  diseases.  The  dentist  is  part  of  the 
Medical  Department,  and  nothing  is  so  disheartening  as 
feeling  that  through  carelessness  something  has  been  al- 
lowed to  spread,  or  that  a  life  was  lost;  in  military  life 
a  thing  like  that  sticks.  Medical  officers  are  constantly 
under  that  strain  in  the  field.  The  writer  has  heard  en- 
listed men  say  they  wTould  ' '  shoot  that  doctor  in  the  back" 
as  soon  as  they  had  an  opportunity ;  and  usually  there  is 
some  reason  for  such  utterances.  Life  is  not  always  rosy 
in  the  field ;  it  is  real,  hard  work ;  it  requires  mental  bal- 
ance and  a  constantly  aggressive  spirit  to  stop  these  dis- 
eases. If  a  man  does  not  remember  the  underlying  prin- 
ciples all  the  time,  he  is  going  to  feel  very  humiliated 
when  somebody  criticizes  him  for  being  careless  and  al- 
lowing something  to  get  by  that  he  should  have  then  and 
there  stopped. 

Commanding  Officers  Responsible  for  the  Sanitary  Con- 
ditions That  Exist  in  Their  Command. — That  means  the 
commanding  officer  of  the  regiment,  of  the  company.  The 
dental  officer  has  no  authority  to  enforce  sanitation ;  he 
is  there  only  in  an  advisory  capacity,  and  he  advises 
that  certain  things  be  done,  otherwise  dire  results  will 
follow;  but  he  must  be  able  to  show  the  commanding  offi- 
cer that  this  situation  confronts  him;  and  one  may  be 
sure  that  the  officer  in  command  is  just  as  afraid  of 
anything  breaking  out  in  his  regiment  as  his  advisors 
are  and  he  is  going  to  take  every  care  of  those  troops  if 
he  can.    But  he  does  not  want  to  take  a  lot  of  unneces- 


FIELD  SERVICE  REGULATIONS  443 

sary  precautions  and  must  be  shown,  and  always  can 
be  shown  by  a  capable  medical  man.  As  has  been  said 
before,  it  is  unwise  to  write  official  communications 
when  one  can  possibly  avoid  it;  but  if  it  is  necessary  to 
do  so,  the  story  must  be  stated  absolutely  in  the  body  of 
the  letter;  not  exaggerated  or  minimized,  but  put  down 
just  as  it  is.  "When  a  medical  or  dental  officer  finds  a  com- 
manding officer  who  is  a  little  careless  about  following 
these  recommendations  he  may  have  to  write  him  every 
day.  At  the  first  opportunity,  instead  of  going  over  his 
head,  it  is  the  writer's  practice  to  get  him  alone  where  no 
one  can  overhear  the  talk.  He  may  prefer  all  the  charges 
he  wishes  with  no  witnesses,  but  if  he  can  get  the  com- 
manding officer  out  in  the  middle  of  the  night  and  do  no 
more  than  impress  upon  him  the  fact  that  he  is  absolutely 
in  earnest,  it  is  worth  while.  The  doctor  can  tell  him  that 
if  disease  comes  it  will  be  the  commanding  officer's  fault. 
The  medical  officers  must  be  listened  to;  their  word  to- 
day is  law  in  the  Army,  and  what  they  recommend  the 
line  officer  must  live  up  to.  There  are  officers  who  do 
not  care  a  rap  for  the  medical  men,  but  they  have  not 
the  nerve  to  refuse  to  do  what  is  suggested,  and  they 
will  do  it.  If  an  epidemic  occurs  after  disregard  of  the 
advice  of  the  medical  man,  the  commanding  officer's 
efficiency  record,  of  which  each  one  is  proud,  imme- 
diately goes  to  smash;  on  that  is  stated  the  fact  that 
in  spite  of  advice  from  the  medical  officer  he  allowed 
certain  conditions.  Generally,  however,  medical  officers 
are  the  most  tactful  men;  they  encourage  the  best 
of  feeling  with  their  commanding  officers ;  but  if  it  ever 
comes  to  an  issue  they  can  fight  just  as  hard,  and  with 
medical  education  usually  fight  much  more  cleverly  than 
the  commanding  officer  in  sanitary  matters. 

The  Sanitary  Inspector.— Sanitary  inspectors  are  staff 
officers  attached  to  a  division  who  check  up  the  work  of 
the  medical  or  other  organizations  and  report  the  results 
of  their  inspections.    It  is  necessary  to  have  a  check  on 


444  MILITARY  ADMINISTRATION 

everything.  Where  one  medical  man  is  found  efficient, 
another  may  not  be;  both  may  be  good  fellows,  but  their 
work  may  not  be  equally  efficient.  For  that  reason  the 
sanitary  officer  checks  it. 

Service  in  Camps. — An  infirmary  is  nothing  but  a  tent, 
maybe  twro  tents,  with  an  ordinary  amount  of  sanitary 
material  and  a  man  in  charge  of  the  whole.  To  this  point 
the  medical  men  may  bring  their  wounded  and  leave  them 
if  necessary,  if  they  are  slightly  indisposed.  The  more 
important  cases  are  transferred,  on  a  transfer  card,  a 
copy  of  the  register  card,  to  some  more  permanent  organ- 
ization in  the  rear,  where  they  may  be  properly  cared 
for.  If  the  camp  were  suddenly  flooded  with  a  lot  of 
cases,  they  would  be  sent  to  the  field  hospitals  if  no  per- 
manent hospitals  were  available. 

The  ambulance  corps  have  their  ambulances,  and  not 
only  ambulances  but  wagons  with  mules,  in  which  they 
store  their  canvas  and  supplies,  and  they  move  along 
behind  the  fighting  troops  in  general;  behind  them  are 
the  field  hospitals,  which  are  nothing  but  tents  with  med- 
ical personnel,  bedding  and  equipment.  As  the  forces 
go  ahead  the  ambulances  and  field  hospitals  follow  in 
the  sanitary  train,  in  which  are  certain  supplies  for  the 
front  and  all  those  outfits  which  are  kept  packed  to  be 
ready  for  immediate  use.  If  a  building  is  found  a  field 
hospital  is  set  up  there.  The  men  are  put  under  cover 
anywhere  rather  than  under  canvas;  canvas  equipment 
at  best  is  dirty  and  cold,  and  tents  are  never  used  if 
better  shelter  for  the  sick  and  wounded  can  be  obtained. 

Non-combatants.— Every  member  of  the  medical  de- 
partment wears  on  his  arm  a  red  cross,  so  in  the  field 
service  dentists  will  wear  that  badge  all  the  time.  That 
shows  that  they  are  non-combatants  and  are  entitled  to 
all  the  respect  and  consideration  that  the  Geneva  Con- 
vention gives  to  that  class.  There  have  been  two  great 
conventions,  the  Hague  Convention  and  the  Geneva  Con- 
vention.  The  Hasrue  Convention  has  to  do  with  the  fight- 


PERSONAL  EQUIPMENT  445 

ing  troops,  the  Geneva  with  others ;  and  it  is  well  worth 
while  to  consider  their  deliberations.  If  any  army  is  op- 
erating in  the  vicinity  of  a  neutral  state  or  power,  all 
those  wounded  may  be  turned  over  to  this  neutral  power 
to  be  interned  until  the  end  of  the  war.  In  the  Middle 
Ages  they  used  to  sweetly  and  calmly  despatch  those  who 
were  wounded,  and  even  with  the  advice  of  the  surgeon 
who  accompanied  the  army.  Today  in  Mexico  much  the 
same  thing  takes  place;  and  if  one  can  give  credence  to 
what  one  hears  of  matters  in  Europe  today,  the  Apache 
Indian  in  his  palmiest  days  committed  no  more  excesses 
than  are  committed  in  Europe  now. 

Red  Cross.— If  an  officer  is  in  the  field  and  puts  up  a 
red  cross  flag  and  a  battery  commander  puts  a  battery 
up  and  commences  to  fire,  the  red  cross  flag  is  torn  down. 
One  must  not  by  any  chance  deceive  the  enemy  by  the 
use  of  that  red  cross  flag;  and  care  must  be  taken  that  no- 
body takes  advantage  of  the  sanctity  supposed  to  sur- 
round it. 

PERSONAL  EQUIPMENT 

Field  Service  Uniform. — The  field  service  uniform  is 
chiefly  a  flannel  shirt  and  breeches,  and,  depending  on 
the  weather,  one  may  add  a  sweater  or  jersey.  The  shirt 
is  made  out  of  very  heavy  wool  and  the  jersey  is  sleeve- 
less. It  is  a  very  comfortable  outfit.  The  hat  is  a  cam- 
paign hat  with  a  stiff  brim  with  a  strap  and  a  cord 
around  the  crown.  This  officer's  cord  is  a  mixture  of 
gold  and  black,  and  is  not  the  general  officer's  cord, 
which  is  a  solid  gold  braid  of  the  same  sort.  The  strap 
insures  its  staying  on  while  riding  or  under  almost  any 
condition.  The  brim,  being  stiff,  is  not  always  flapping 
up  and  down.  In  very  hot  weather  the  brim  gives  good 
shade  and  the  hat  is  comparatively  cool. 

Field  Glasses.— There  are  one  or  two  other  things:  field 
glasses  and  also  what  is  called  a  map  case.     These  are 


446  MILITARY  ADMINISTRATION 

very  essential  for  the  reason  that  an  officer  often  gets 
orders  to  be  at  a  certain  place  at  a  certain  time,  and  un- 
less he  knows  where  the  place  is  on  the  map,  he  is  liable 
not  to  get  there.  He  has  to  have  the  power  of  observation 
developed  to  a  high  extent,  so  he  carries  field  glasses.  It 
makes  no  difference  what  kind  he  carries.  There  are 
hundreds  of  kinds  in  the  market.  The  high  priced  ones 
are  generally  the  ones  with  large  magnifying  power  and 
wide  fields,  but  the  cheaper  ones  are  most  serviceable. 
If  the  horse  rolls  over  a  cheap  pair  they  can  be  twisted 
back  into  shape  again,  which  could  not  be  done  with  a  bet- 
ter glass.  One  should  never  buy  a  pair  of  glasses  of  so 
high  power  that  the  image  trembles.  It  is  not  essential 
for  a  medical  officer  to  buy  glasses,  but  he  is  supposed  to 
have  them ;  and  a  fairly  cheap  pair,  with  good  illumination 
and  with  magnifying  power,  are  more  or  less  undistort- 
able. 

Map  Case.— It  becomes  necessary,  of  course,  in  finding 
the  location  of  certain  places,  to  orient  oneself,  that  is,  find 
out  where  one  is.  For  that  reason  a  map  case  is  carried. 
In  this  is  a  military  map  which  is  folded  to  show  that  por- 
tion that  one  wants  to  use.  The  case  is  provided  with  a 
celluloid  cover  which  protects  the  face  of  the  map.  Notes 
can  be  made  on  this  celluloid  over  the  map.  One  picks  out 
the  place  on  the  map  where  he  is  located  and  orients  him- 
self by  use  of  the  compass  which  is  mounted  at  the  top ; 
this  is  swung  around  till  north  points  to  north.  For  in- 
stance, a  man's  normal  stride  is  30  inches,  and  he  takes 
120  steps  a  minute.  In  this  way  he  can  estimate  the  dis- 
tance he  has  traveled  and  find  out  where  he  is  by  compar- 
ing it  with  the  scale  at  the  bottom  of  the  map.  If  he  is  on 
horseback,  he  knows  the  pace  of  the  horse,  howT  far  he 
travels  at  a  walk,  how  far  he  travels  at  a  trot,  and  how 
far  he  travels  at  a  gallop  in  a  certain  space  of  time.  This 
is  the  way  orders  come:  "350  yards  south  T.  P.  Butte." 
One  turns  to  the  map  and  finds  the  spot  marked  T.  P. 
Butte.    All  the  elevations  are  marked  on  the  map,  so  one 


PERSONAL  EQUIPMENT  447 

knows  how  high  he  is.  He  simply  watches  the  com- 
pass and  draws  lines  on  the  map  as  he  goes  along.  It 
is  a  simple  matter  to  orient  oneself  properly.  When  one 
gets  to  the  place  where  he  should  be,  he  consults  the 
map  and  proves  the  location  to  be  true.  Then  he  may 
have  to  report  back  that  he  has  reached  the  place.  He 
may  have  to  make  a  sketch  of  the  location,  so  that  he 
can  send  back  word  not  only  that  he  has  reached  the 
spot,  but  some  information  as  to  what  sort  of  place  it  is. 
In  this  information  is  included  anything  which  he  may 
have  seen  and  which  he  thinks  the  commanding  officer 
ought  to  know.  If  it  is  a  sanitary  situation  that  a  person 
is  to  take  up,  he  must  make  certain  notes  on  the  sanita- 
tion.   Therefore  a  map  is  indispensable. 

The  pistol  is  strapped  against  the  officer's  leg  so  that 
it  may  be  drawn  easily  and  will  not  keep  flapping  up  and 
down  while  riding;  otherwise  it  would  soon  gall  the  leg. 
Pistols  are  not  ordinarily  carried  by  Medical  Department 
men,  except  on  such  service  as  the  rules  of  the  Geneva 
Convention  do  not  apply  to,  where  it  is  necessary  for 
the  officer  to  protect  himself.  The  pistol  is  a  .45  caliber, 
automatic,  very  close  shooting.  One  can  shoot  at  200 
yards  and  make  good  targets,  allowing  for  elevation.  The 
shells  are  held  in  a  clip  in  the  breech,  that  is,  an  empty 
clip.  The  cartridges  are  sent  into  place  by  the  recoil. 
A  person  can  fire  very  fast  and  very  effectively  with  such 
a  weapon.  The  cartridges  which  are  used  in  the  gun  are 
carried  in  the  clip  container.  Back  of  the  cartridges  is  a 
spring  which  shoots  them  into  place.  The  clips  are  kept 
where  one  can  get  hold  of  them. 

The  first-aid  packet  is  kept  in  a  little  pouch  where  one 
can  get  at  it  easily  and  contains  two  sterilized  pads,  a 
roll  of  gauze,  safety  pins,  etc.  On  the  packet  is  a  little 
ring.  The  finger  is  put  in  the  ring,  which  is  pulled,  and 
the  packet  opens  like  a  can  of  sardines. 

The  flannel  shirt  is  the  best  one  to  wear  in  either  winter 
or  summer.     In     the  summertime  it  protects  from  the 


448  MILITARY  ADMINISTRATION 

sun's  rays  and  absorbs  the  perspiration.  One  should 
under  no  circumstances  in  hot  sunlight  strip  down  to  the 
undershirt.  Some  woolen  goods  should  be  kept  on  to  pro- 
tect the  skin.  In  hot  climates  it  is  essential  to  have  sun 
glasses,  no  matter  what  type,  otherwise  the  glare  of  the 
sun  and  the  dust  will  ruin  the  eyes  in  no  time,  so  that 
one  cannot  see  anything.  The  officer  must  always  carry 
glasses. 

The  breeches  for  use  in  field  service  are  to  be  chosen 
mainly  for  comfort.  Old  breeches  should  be  used  in  the 
field,  a  comfortable  pair  with  plenty  of  looseness  around 
the  hip.  Ready-made  clothes  do  not  fit  or  feel  well.  It  is 
better  to  have  them  made  by  a  tailor.  A  comfortable 
pair  of  riding  boots  is  the  proper  thing.  No  man  ever 
appears  without  spurs  on  his  boots. 

Miscellaneous  Information 

Saluting".— There  are  certain  exceptions  in  the  mat- 
ter of  saluting.  A  man  eating  does  not  salute  or  stand 
at  attention.  A  man  working  does  not  salute.  A  man 
occupied  with  his  ordinary  work  never  stops  to  salute 
anyone.  Even  soldiers  at  work  do  not  stand  to  salute 
an  officer  if  they  are  preoccupied  with  some  duty  or 
busy  hustling  along  with  a  couple  of  bundles  in 
their  arms.  The  reason  is  perfectly  evident.  The  man 
is  busy  and  his  arms  are  occupied.  It  would  almost 
be  analogous  to  a  soldier  on  the  firing  line  stopping  fir- 
ing on  seeing  an  officer.  It  would  be  farcical.  The  cus- 
toms of  the  service  enter  into  every  question  of  that  sort, 
and  one  often  sees  jokes  in  the  papers  about  it.  The 
salute  is  different  from  what  it  was  twenty  years  ago. 
The  right  hand  is  always  used,  bringing  the  arm  sharply 
to  position,  taking  the  shortest  distance  the  hand  can 
travel  from  the  head  to  the  hip  and  holding  the  hand 
there  until  the  salute  is  recognized,  when  the  one  first 
saluting  brings  his  hand  down. 


PERSONAL  EQUIPMENT  449 

Books.— There  are  four  important  books  in  connection 
with  army  administration:  the  Army  Regulations,  which 
covers  more  than  all  the  others  together;  a  Manual  of  the 
Medical  Department,  which  controls  professional  life;  the 
Field  Service  Regulations;  and  there  is  still  another 
which  deals  with  general  orders,  circulars  and  bulletins 
of  the  War  Department.    This  latter  is  apt  to  be  changed. 

In  regard  to  orders,  one  gets  from  the  War  Depart- 
ment general  orders,  which  relate  to  big  things;  special 
orders,  which  relate  to  individuals  particularly ;  bulletins 
and  circulars,  which  relate  to  opinions  particularly,  some 
kind  of  property  that  should  be  issued,  or  the  way  in 
which  it  should  be  issued.  An  officer  not  only  gets  orders, 
circulars  and  bulletins  from  the  War  Department,  but 
he  gets  some  from  the  Militia ;  some  from  the  State  of 
Massachusetts  and  some  from  the  Medical  Department. 
It  is  difficult  therefore  for  an  officer  to  get  the  right  order 
or  the  right  circular  or  the  right  bulletin  to  apply  to  each 
individual  circumstance  or  case  that  comes  up.  Most  of 
the  National  Guard  officers  have  been  complaining 
against  that  kind  of  red  tape  and  are  trying  to  simplify 
things.  It  is  desired  to  cut  out  this  mass  of  red  tape  that 
keeps  everyone  tied  up  all  the  time.  The  officers  want  to 
have  one  set  of  orders  and  have  only  that  portion  of  the 
order  sent  that  refers  to  the  particular  business  on  hand. 
An  officer  wants  his  own  orders  concerning  his  own  busi- 
ness with  the  rest  eliminated.  However,  the  War  Depart- 
ment is  now  planning  to  issue  a  single  set,  and  to  elim- 
inate anything  that  does  not  concern  particular  depart- 
ment work.  It  cuts  out  all  the  bulletins  and  circulars. 
The  authorities  in  Washington  are  beginning  to  lop  off 
the  branches  of  the  great  tree  of  red  tape,  and  it  is  hoped 
that  they  will  prune  it  well. 

Getting  Settled  in  Quarters. — The  new  medical  officer 
reports  to  the  colonel  as  soon  as  possible.  The  colonel 
will  introduce  him  to  the  officers  of  the  mess,  and  to  his 
own  family  if  he  has  one.    Whenever  the  colonel  implies 


450  MILITARY  ADMINISTRATION 

thai  he  wants  a  certain  thing  done  it  is  necessary  to  do  it. 
lie  rarely  will  say,  "do  such  and  such  a  thing."  The 
medical  officer  gets  an  order  stating  that  "The  colonel 
desires  so  and  so."  After  having  made  the  regulation 
call,  naturally  one  thinks  about  his  quarters,  because 
his  trunk  is  somewhere  on  the  road.  The  quartermas- 
ter is  the  man  who  has  charge  of  all  the  transportation. 
The  new  officer  introduces  himself  and  says,  for  instance, 
"Captain  Smith,  I  am  Lieutenant  of  the  Med- 
ical Corps,  assigned  to  this  regiment,  and  I  have  a  trunk 
somewhere  on  the  road."  He  may  then  mention  that  he 
needs  a  place  to  sleep  in.  It  is  the  business  of  the  quar- 
termaster to  send  somebody  after  the  new  officer's  trunk, 
to  find  quarters  and  make  him  comfortable.  He  may  not 
be  able  to  get  the  trunk  or  to  find  quarters,  but  he  will  see 
that  the  medical  officer  is  made  comfortable  until  the 
quarters  are  ready.  The  9  ft.  by  9  ft.  tent  is  set  up  and 
the  person  takes  possession  and  proceeds  to  make  it  look 
as  homelike  as  possible.  When  the  bedding  roll  comes  the 
cot  bed  is  set  up,  the  clothing  put  on  it  and  after  the  trunk 
comes  a  line  is  hung  up  from  one  pole  to  another,  to  hang 
the  clothes  on.  Or  one  may  have  one  of  these  patent  com- 
bination racks  with  hooks  around  the  pole.  Usually  both 
are  necessary,  because  more  or  less  clothing  accumulates 
after  a  while.  The  tent  flap  is  raised  to  get  light  and 
air  and  a  place  is  found  to  hang  the  lantern.  It  is  al- 
ways inconvenient,  when  the  shades  of  night  are  coming 
on,  to  have  no  light. 

The  new  man  will  then  be  introduced  to  the  various 
officers;  they  will  invite  him  to  take  a  drink  or  have  a 
cigar,  and  life  will  start  off  properly.  There  is  no  drink- 
ing now  and  the  cigars  are  getting  poorer  every  year,  but 
the  men  are  comfortable  and  happy  and  like  the  life.  One 
can  soon  size  up  some  fellow  as  being  likable  and  culti- 
vate him.  Generally  the  gruff  type  are  the  best  hearted 
and  the  best  soldiers.  If  some  fellow  just  looks  at  the 
new  arrival  and  moves  on  the  latter  need  not  be  rebuffed. 


PERSONAL  EQUIPMENT  451 

After  a  while  lie  will  appreciate  good  soldiers,  not  so 
much  for  their  social  as  for  their  soldierly  qualities. 

One  salutes  the  colonel  when  approaching  him  and 
when  leaving.  The  new  man  gets  up  on  his  feet,  throws 
his  chest  out,  and  starts.  The  colonel  will  say,  "There 
goes  a  good  soldier."  The  first  impression  is  important. 
Whatever  a  man  does,  he  never  comes  into  camp  with  an 
umbrella  over  his  head.  If  a  new  man  is  ordered  to 
report  before  he  has  a  chance  to  get  his  uniform,  he 
reports  in  civilian  clothes,  apologizes  and  explains  that 
he  had  no  opportunity  to  equip  himself.  Perhaps  he  feels 
he  is  making  a  breach  of  etiquette,  but  he  explains  that 
he  is  green  at  the  game. 

The  proper  way  of  terminating  a  conversation  with  a 
senior  officer  is  to  leave  as  soon  as  convenient.  The 
colonel  will  ask  the  new  officer  to  sit  down.  He  will  ask 
where  he  came  from,  whether  he  has  any  equipment,  or 
something  pertaining  to  his  arrival  in  the  regiment.  The 
minute  one  finds  the  conversation  beginning  to  flag  the 
least  particle,  he  should  stand  up  promptly  and  termi- 
nate the  interview  with  some  sentence  like  "Well, 
Colonel,  I  think  I  have  taken  up  enough  of  your  time, 
and  if  you  will  pardon  me  I  will  leave."  One  thing  no- 
ticeable in  the  Army  is  that  most  of  the  senior  officers  are 
more  of  the  social  type  than  of  the  fighting  type,  although 
many  are  of  both. 

Rubber  Boots.  — Rubbers  are  not  commonly  worn  but  it 
is  a  good  thing  to  add  rubber  boots  to  the  equipment. 
One  should  never  go  into  the  field  without  having  rubber 
boots  and  a  rubber  blanket.  The  writer  has  been  out  on 
horseback  with  rubber  boots  for  two  days  in  blazing  sun- 
shine. He  rode  in  his  stocking  feet  but  never  gave  up 
those  boots.  In  weather  which  is  liable  to  be  wet  rubber 
boots  should  be  most  certainly  worn  because  if  not  the 
feet  get  wet,  one  is  soaked,  cold  and  shivery  and  there  is 
no  opportunity  to  get  dry.  A  whole  regiment  may  go  into 
a  camp  on  a  field  with  the  grass  almost  covered  with 


452  MILITARY  ADMINISTRATION 

water.    The  men  simply  spread  out  their  rubber  blankets, 
splash  down  into  them,  and  go  off  to  sleep. 

The  present  chapter  is  designed  to  instruct  the  medical 
or  dental  officer  on  necessary  points  in  field  service,  but 
if  a  man  wants  to  know  anything  after  going  into  camp 
he  must  go  to  the  adjutant  or  to  the  senior  medical  officer 
for  further  information. 


CHAPTER  XVII 

History  of  military  dental  laws 
Frederick  A.  Keyes,  D.M.D. 

The  United  States  was  the  first  country  to  recognize 
the  importance  of  a  Dental  Corps  for  its  army.  A  brief 
history  of  the  rapid  advance  made  by  the  Dental  Corps 
may  be  obtained  by  reading  the  following  extracts  of  vari- 
ous bills  which  have  been  introduced  from  1901  to  1911 
and  from  1911  to  1916. 

For  much  of  this  information  the  author  is  indebted 
to  Lieut.  S.  D.  Boak,  U.  S.  D.  C. 

Extract  No.  1  is  the  original  law  establishing  a  Dental 
Corps  in  the  United  States  Army.  This  corps,  as  can 
easily  be  seen,  was  made  up  entirely  of  contract  dental 
surgeons  who  were  not  commissioned  officers.  From  1901 
to  1911  various  bills  were  introduced  into  Congress  each 
year,  to  give  the  Dental  Corps  a  commissioned  personnel, 
but  without  success. 

ORGANIZATION  OF  THE   MEDICAL   DEPARTMENT 

Extract  from  Act  of  Congress  Approved  February 

2,  1901 

This  act  provided: 

That  the  Surgeon  General  of  the  Army,  with  the  approval  of 
the  Secretary  of  War,  be,  and  is  hereby,  authorized  to  em- 
ploy dental  surgeons  to  serve  the  officers  and  enlisted  men  of 
the  Regular  and  Volunteer  Army,  in  the  proportion  of  not  to 
exceed  one  for  every  one  thousand  of  said  Army,  and  not  ex- 
ceeding thirty  in  all.  Said  dental  surgeons  shall  be  emploj'ed  as 
contract  dental  surgeons  under  the  terms  and  conditions  appli- 

453 


454     HISTORY  OF  MILITARY  DENTAL  LAWS 

cable  to  Army  contracl  surgeons,  and  shall  be  graduates  of  stan- 
dard medical  or  dental  colleges,  trained  in  the  several  branches 
of  dentistry,  of  good  moral  and  professional  character,  and 
shall  pass  a  satisfactory  professional  examination: 

That  three  of  the  number  of  dental  surgeons  to  be  employed 
shall  be  first  appointed  by  the  Surgeon  General,  with  the  ap- 
proval of  the  Secretary  of  War,  with  refei'ence  to  their  fitness 
for  assignment,  under  the  direction  of  the  Surgeon  General,  to 
the  special  service  of  conducting  the  examinations  and  super- 
vising the  operations  of  the  others;  and  for  such  special  service 
an  extra  compensation  of  sixty  dollars  a  month  will  be  allowed: 

That  dental  college  graduates  now  employed  in  the  Hospital 
Corps  who  have  been  detailed  for  a  period  of  not  less  than  twelve 
months  to  render  dental  service  to  the  Army  and  who  are  shown 
by  the  reports  of  their  superior  officers  to  have  rendered  such 
service  satisfactorily  may  be  appointed  contract  dental  surgeons 
without  examination. 

The  following  extract  is  from  the  law  establishing  a 
commissioned  personnel  for  the  Dental  Corps,  which, 
however,  limited  the  number  of  commissioned  dentists  to 
sixty.  The  law  of  1911  gave  dentists  only  one  commis- 
sioned grade,  that  of  First  Lieutenant.  From  1911  to 
1916,  again,  various  bills  were  introduced  to  secure  addi- 
tional grades. 

FORM    142 
War  Department,  Surgeon  General's  Office 
(Revised  July  2,  1913) 

CIRCULAR   OF   INFORMATION 

In  relation  to  appointment  in  the  Dental  Corps  of  the  United 
States  Anny;  the  requisite  qualifications,  examination  of  ap- 
plicants, etc. 

The  act  of  Congress  approved  March  3,  1911,  establishing  the 
Dental  Corps  of  the  Army,  is  as  follows: 

Hereinafter  there  shall  be  attached  to  the  Medical  Department 
a  Dental  Corps,  which  shall  be  composed  of  dental  surgeons  and 
acting  dental  surgeons,  the  total  number  of  which  shall  not  ex- 
ceed the  proportion  of  one  to  each  thousand  of  actual  enlisted 


ORGANIZATION  OF  MEDICAL  DEPARTMENT  455 

strength  of  the  Army;  the  number  of  dental  surgeons  shall  not 
exceed  sixty,  and  the  number  of  acting  dental  surgeons  shall  be 
such  as  may,  from  time  to  time,  be  authorized  by  law.  All  orig- 
inal appointments  to  the  Dental  Corps  shall  be  as  acting  dental 
surgeons,  who  shall  have  the  same  official  status,  pay,  and  allow- 
ances as  the  contract  dental  surgeons  now  authorized  by  law. 
Acting  dental  surgeons  who  have  served  three  years  in  a  manner 
.  satisfactory  to  the  Secretary  of  "War  shall  be  eligible  for  appoint- 
ment as  dental  surgeons,  and,  after  passing  in  a  satisfactory 
manner  an  examination  which  may  be  prescribed  by  the  Secretary 
of  War,  may  be  commissioned  with  the  rank  of  First  Lieutenant 
in  the  Dental  Corps  to  fill  the  vacancies  existing  therein.  Offi- 
cers of  the  Dental  Corps  shall  have  rank  in  such  corps  according 
to  the  date  of  their  commissions  therein  and  shall  rank  next  be- 
low officers  of  the  Medical  Reserve  Corps.  Their  right  to  com- 
mand shall  be  limited  to  the  Dental  Corps.  The  pay  and  allow- 
ances of  dental  surgeons  shall  be  those  of  First  Lieutenants,  in- 
cluding the  right  to  retirement  on  account  of  age  or  disability, 
as  in  the  case  of  other  officers : 

The  time  served  by  dental  surgeons  shall  be  reckoned  in  com- 
puting the  increased  service  pay  of  such  as  are  commissioned 
under  this  act.  The  appointees  as  acting  dental  surgeons  must 
be  citizens  of  the  United  States  between  twenty-one  and  twenty- 
seven  years  of  age,  graduates  of  a  standard  dental  college,  of 
good  moral  character  and  good  professional  education,  and  they 
shall  be  required  to  pass  the  usual  physical  examination  required 
for  appointment  in  the  Medical  Corps,  and  a  professional  exam- 
ination which  shall  include  tests  of  skill  in  practical  dentistry 
and  of  proficiency  in  the  usual  subjects  of  a  standard  dental 
college  course : 

This  applies  to  the  contract  dental  surgeons  in  the  service  at 
the  time  of  the  passage  of  this  act,  whose  efficiency  reports  and 
entrance  examinations  are  satisfactory. 

The  Secretary  of  War  is  authorized  to  appoint  boards  of  three 
examiners  to  conduct  the  examinations  herein  prescribed,  one 
of  whom  shall  be  a  surgeon  in  the  Army  and  two  of  whom  shall 
be  selected  by  the  Secretary  of  War  from  the  commissioned  den- 
tal surgeons. 

The  next  extract  shows  the  House  bill,  part  of  which 
was  finally  enacted  as  the  National  Defense  Act  of 
June  3,  1916.  In  the  Sixty-fourth  Congress,  First  Ses- 
sion, House  of  Representatives  12766,  Report  No.  297, 


450     HISTORY  OF  MILITARY  DENTAL  LAWS 

line  14,  Mr.  Hay,  from  the  Committee  on  Military  Af- 
fairs, reported  the  following  bill,  which  was  referred  to 
the  committee  of  the  whole  House  and  ordered  to  be 
printed : 

A  Bill  to  Increase  the  Efficiency  of  the  Military  Estab- 
lishment of  the  United  States 

Provided:  That  hereafter  the  Dental  Corps  of  the  Army  shall 
consist  of  the  number  of  officers  in  said  corps  now  provided  by 
law,  and  that  there  shall  be  thirty-five  captains  in  said  corps; 
that  appointees  to  the  grade  of  first  lieutenant  in  said  corps  shall 
be  not  less  than  twenty-two  years  and  not  more  than  thirty  years 
of  age;  and  that  promotion  to  the  grade  of  captain,  herein  pro- 
vided for,  shall  be  subject  to  an  examination  before  a  board  con- 
sisting of  not  more  than  three  officers  of  the  Medical  and  Dental 
Corps  of  the  Army,  to  be  appointed  by  the  Secretary  of  War; 
and  that  the  captains  provided  for  in  this  Act  shall  be  appointed 
from  the  present  members  of  the  Dental  Corps  who  have  had 
five  years'  service  in  said  Corps. 

The  following  extract  is  the  amendment  introduced  by 
Senator  Pomerene  to  Senate  bill  4840,  which  embodied  the 
above  grades.  In  the  Sixty-fourth  Congress,  First  Ses- 
sion, Senate  4840,  in  the  Senate  of  the  United  States, 
March  22,  1916,  was  ordered  to  lie  on  the  table  and  to 
be  printed  and  an  Amendment  proposed  to  Defense  Bill. 
On  page  12  of  the  former  bill  the  paragraph  commencing 
with  line  16  and  ending  with  line  7  on  page  13  is  struck 
out,  and  in  lieu  thereof  the  following  is  inserted : 

The  President  is  hereby  authorized  to  appoint  and  commis- 
sion, by  and  with  the  advice  and  consent  of  the  Senate,  dental 
surgeons  at  the  rate  of  one  for  each  one  thousand  enlisted  men 
of  the  line  of  the  Army.  Officers  of  the  Dental  Corps  shall  have 
the  rank,  pay,  and  allowances  of  Fh'st  Lieutenants  until  they 
have  completed  five  years  of  service,  when  they  shall  be  eligible 
for  promotion  to  the  grade  of  Captain.  Officers  of  the  Dental 
Corps,  after  fifteen  years  of  service,  shall  be  eligible  for  promo- 
tion to  the  grade  of  Major : 

That  the  number  of  majors  at  no  time  shall  exceed  twenty-two 
per  centum  of  the  strength  of  the  Dental  Corps : 


ORGANIZATION  OF  MEDICAL  DEPARTMENT  457 

That  the  officers  of  the  Dental  Corps  shall  have  the  rank,  pay, 
and  allowances,  including-  the  right  to  retirement  on  account  of 
age,  service,  or  disability,  as  officers  of  like  grade  in  the  Medical 
Corps  of  the  Army,  and  that  service  heretofore  rendered  as  con- 
tract dental  surgeon  shall  be  computed  as  commissioned  service: 

That  promotion  in  the  Dental  Corps  shall  be  governed  by  Act 

of  April  twenty-third,  nineteen  hundred  and  eight,  section  five, 

.as  prescribed  for  the  Medical  Corps,  except  that  the  examining 

and  review  boards  shall  consist  of  one  medical  and  two  dental 

officers. 

The  bill  as  it  was  passed  and  finally  enacted  into  law 
is  shown  below.  In  the  National  Defense  Act,  June  3, 
1916,  Section  10,  pertaining  to  Medical  Department,  it 
was  enacted  that 

The  President  is  hereby  authorized  to  appoint  and  commis- 
sion, by  and  with  the  advice  and  consent  of  the  Senate,  dental 
surgeons,  who  are  citizens  of  the  United  States  between  the  ages 
of  twenty-one  and  twenty-seven  years,  at  the  rate  of  one  for  each 
one  thousand  enlisted  men  of  the  line  of  the  Army.  Dental 
surgeons  shall  have  the  rank,  pay,  and  allowance  of  First  Lieu- 
tenants until  they  have  completed  eight  years'  service.  Dental 
surgeons  of  more  than  eight  but  less  than  twenty-four  years' 
service  shall,  subject  to  such  examination  as  the  President  may 
prescribe,  have  the  rank,  pay,  and  allowances  of  Captains.  Den- 
tal surgeons  of  more  than  twenty-four  years'  service  shall,  sub- 
ject to  such  examination  as  the  President  may  prescribe,  have 
the  rank,  pay,  and  allowances  of  Major: 

That  the  total  number  of  dental  surgeons  with  rank,  pay  and 
allowances  of  major  shall  not  at  any  time  exceed  fifteen : 

That  all  laws  relating  to  the  examination  of  officers  of  the 
Medical  Corps  for  promotion  shall  be  applicable  to  dental  sur- 
geons. 

Since  that  time  the  General  Staff  of  the  Army  intro- 
duced a  universal  training  bill.  This  was  of  interest  to 
dentists  in  that  the  length  of  service  in  the  different 
grades  of  the  Dental  Corps  was  reduced.  In  the  bill, 
House  of  Representatives,  92,  April  2,  1917,  line  10,  it  is 
stated : 

The  permanent  personnel  of  the  Dental  Corps  shall  consist  of 
five  hundred  dental   surgeons.     Dental  surgeons   shall  have  the 


458     HISTORY  OF  MILITARY  DENTAL  LAWS 

rank,  pay  and  allowances  of  First  Lieutenants  until  they  have 
completed  five  years'  service.  Dental  surgeons  of  more  than  nine 
but  less  than  nineteen  years'  service  shall,  subject  to  such  exam- 
ination as  the  President  may  prescribe,  have  the  rank,  pay,  and 
allowances  of  Captains.  Dental  surgeons  of  more  than  nineteen 
years'  service  shall,  subject  to  such  examination  as  the  President 
may  prescribe,  have  the  rank,  pay,  and  allowances  of  Majors. 

The  following  extract  shows  that  the  dental  profession 
is  striving  for  equality  of  rating  with  the  medical  pro- 
fession.*     In   the   Amendment   introduced   by    Senator 
Lodge  to  bill,  House  of  Representatives,  4897,  it  was  pro-^ 
posed  that : 

Hereinafter  the  Dental  Corps  shall  consist  of  commissioned 
officers  of  the  same  grades  and  proportionally  distributed  among 
such  grades  as  are  now  or  may  hereafter  be  provided  by  law  for 
the  Medical  Corps,  who  shall  have  the  rank,  pay  and  allowances 
of  the  officers  of  corresponding  grades  in  the  Medical  Corps, 
including  the  right  to  retirement  as  in  the  case  of  officers;  and 
there  shall  be  one  dental  officer  for  every  one  thousand  of  the 
total  strength  of  the  Regular  Army,  authorized  from  time  to 
time  by  law : 

That  all  laws  relating  to  the  examination  of  officers  of  the 
Medical  Coi-ps  for  promotion  shall  be  applicable  to  officers  of 
the  Dental  Corps : 

That  Dental  Examining  and  Review  Boards  shall  consist  of  one 
officer  of  the  Medical  Corps  and  two  officers  of  the  Dental  Corps. 

That  immediately  following  the  approval  of  this  act  all  Dental 
Surgeons  then  in  active  service  .shall  be  recommissioned  in  the 
Dental  Corps  in  the  grades  herein  authorized  in  the  order  of 
their  seniority  and  without  loss  of  relative  rank  in  the  Army. 

That  First  Lieutenants  in  the  Medical  Department  shall  be 
promoted  to  the  grade  of  Captain  upon  the  completion  of  three 
years'  service  in  that  grade  in  the  Medical  Department  and  upon 

*  The  latest  legislation  relative  to  this  matter  is  practically  the  new 
Lodge  amendment  which  we  have  quoted  above  as  having  been  passed  in 
the  House  of  Representatives,  Bill  4897.  This  last  bill  passed  the  Senate 
and  was  signed  by  the  President  and  became  a  law  June  6,  1917.  The  Judge 
Advocate  General 's  opinion  as  to  the  construction  of  this  statute  has  not 
yet  been  approved  by  the  Secretary  of  War,  whose  interpretation  has  been 
asked  by  the  Surgeon  General.  On  the  basis  of  300,000  enlisted  men  it 
will  probably  commission  300  officers  in  the  Dental  Corps,  and  as  nearly 
as  may  be  determined  now,  there  will  be  created  nine  Colonels,  sixteen 
Lieutenant  Colonels,  seventy-one  Majors  and  two  hundred  and  three  Cap- 
tains and  First  Lieutenants. 


THE  DENTAL  CORPS,  U.  S.  AEMY         459 

passing  the  examinations  prescribed  by  the  President  for  promo- 
tion. 

In  order  that  the  connection  between  the  Lodge  Amend- 
ment and  House  Bill  4897  may  be  fully  understood,  the 
latter  is  herewith  incorporated : 

That  during  the  existing'  emergency  Lieutenants  in  the  Medi- 
cal Corps  of  the  Regular  Army  and  of  the  National  Guard  shall 
be  eligible  to  promotion  as  Captain  upon  such  examination  as 
may  be  prescribed  by  the  Secretary  of  War. 

For  further  information  dealing-  with  the  latest  laws, 
etc.,  in  the  Dental  Reserve  Corps,  the  following  circular 
of  information  will  show  the  present  situation  of  the 
Corps : 

FORM  146 

War  Department,  Surgeon  General's  Office 

{Revised  Feb.  27,  1917) 

CIRCULAR    OF    INFORMATION 

In  Relation  to  Appointments  in 

THE  DENTAL  CORPS,  U.  S.  ARMY 

The  Requisite  Qualifications,   Examination  of  Applicants,  etc. 

Constitution  of  the  Corps 

The  Dental  Corps  is  one  of  the  constituent  members  of  the 
Medical  Department  of  the  Army,  of  which  the  other  members 
are  the  Medical  Corps,  the  Veterinary  Corps,  the  Nurse  Corps, 
and  the  Enlisted  Force.  It  consists  entirely  of  officers,  who  are 
commissioned  as  dental  surgeons.  Appointments  therein  are  au- 
thorized at  the  rate  of  1  for  each  1,000  enlisted  men  of  the  line 
of  the  Army.  During  the  first  eight  years  of  their  service  dental 
surgeons  have  the  rank,  pay,  and  allowances  of  First  Lieuten- 
ants. After  eight  years  they  have  the  rank,  pay,  and  allowances 
of  Captains,  and  after  twenty-four  years  the  rank,  pay,  and 
allowances  of  Majors;  subject,  however,  to  such  examination  prior 
to  advancement  as  the  President  may  prescribe,  and  to  the  pro- 
viso that  the  number  of  dental  surgeons  with  the  rank  of  major 
shall  not  at.  any  time  exceed  fifteen. 


460     HISTORY  OF  MILITARY  DENTAL  LAWS 

Officers  of  the  Dental  Corps  have  rank  therein  according  to  the 
dates  of  their  commissions,  and  they  rank  next  below  othcers  of 
the  Medical  Reserve  Corps.  Their  right  to  command  is  limited 
to  the  Dental  Corps. 

Qualifications 

No  applicant  may  under  existing  law  be  commissioned  in  the 
Dental  Corps  unless  he  is  between  21  and  32  years  of  age,  a  citi- 
zen of  the  United  States,  a  graduate  of  a  standard  dental  college, 
and  of  good  moral  character,  nor  unless  he  shall  pass  the  usual 
physical  examination  required  for  appointment  in  the  Medical 
Corps,  and  a  professional  examination  which  shall  include  tests 
of  skill  in  practical  dentistry  and  of  proficiency  in  the  usual 
subjects  of  a  standard  dental  college  course. 

Whether  or  not  the  applicant  is  married  has  no  effect  upon 
his  eligibility  for  the  Dental  Corps. 

Application  for  Appointment 

Application  for  appointment  must  be  made  in  writing,  upon 
the  prescribed  blank  form,  to  the  Surgeon  General  of  the  Army, 
Washington,  D.  C,  who  will  supply  the  blank  upon  request. 
All  the  interrogatories  on  the  blank  must  be  fully  answered. 
In  compliance  with  the  instructions  thereon  the  application  must 
be  accompanied  by  testimonials,  based  upon  personal  acquaint- 
ance, from  at  least  two  reputable  persons,  as  to  the  applicant's 
citizenship,  character,  and  habits. 

The  selection  of  the  candidates  is  made  by  the  Surgeon  Gen- 
eral from  the  applications  submitted,  and  a  formal  invitation  to 
report  for  examination  to  the  most  convenient  examining  board 
in  each  ease  will  be  issued  by  him. 

Examination 

Examinations  are  authorized  and  boards  to  conduct  them  con- 
vened from  time  to  time,  as  may  be  deemed  necessary.  Each 
board  consists  of  one  medical  officer  and  two  dental  surgeons  of 
the  Army.  The  examinations  are  conducted  under  instruction 
from  the  Sm-geon  General.    They  usually  last  six  days. 

No  allowances  can  be  made  for  the  expenses  of  applicants  un- 
dergoing examination,  whether  incurred  in  travel  to  and  from 
or  during  their  stay  at  the  place  of  examination,  as  public  funds 
are  not  available  for  the  payment  of  such  expenses. 


THE  DENTAL  CORPS,  U.  S.  ARMY         461 

Each  applicant,  upon  presenting  himself  to  the  board,  will, 
prior  to  his  physical  examination,  be  required  to  submit  his  di- 
ploma as  a  graduate  of  a  standard  dental  college.  Should  he  fail 
to  do  so  the  examination  will  not  proceed. 

The  examination  consists  of  two  parts : 

(a)  Physical. — The  physical  examination  must  be  thorough. 
Candidates  who  fall  below  G4  inches  in  height  will  be  rejected. 
Each  candidate  must  certify  that  he  labors  under  no  physical 
infirmity  or  disability  which  can  interfere  with  the  efficient  dis- 
charge of  any  duty  which  may  be  required.  Errors  of  refrac- 
tion, if  vision  is  not  below  20/100  in  either  eye,  are  not  causes 
for  rejection,  provided  they  are  not  accompanied  by  ocular  dis- 
ease and  are  entirely  corrected  by  appropriate  glasses. 

The  following  table  is  given  for  convenience  of  reference: 

Physical  Proportions  for  Height,  Weight,  and  Chest 
Measurement 

Chest  Measurement 

Height  Weight         At  expiration        Mobility 

Inches  Pounds  Inches  Inches 

G4                     128                     32  2 

65  130                    32  2 

66  132                    32%  2 

67  134                     33  2 

68  141                    331/4  2% 

69  148                    33V2  2V2 

70  155                    34  2y2 

71  162                     341/4  21/2 

72  169                    3434  3 

73  176                    35%  3 

It  is  not  necessary  that  the  applicant  should  conform  exactly 
to  the  figures  indicated  in  the  foregoing  table.  The  following 
variations  below  standard  given  in  the  table  are  permissible  when 
the  applicant  is  active,  has  firm  muscles,  and  is  evidently  vig- 
orous and  healthy: 

Chest  at 

expiration        AVeight 
Height  (inches)         (pounds) 

64  and  under  68 2  8 

68  and  under  69 2  12 

69  and  under  70 2  15 

70  and  upward 2  20 


4G2     HISTORY  OF  MILITARY  DENTAL  LAWS 

(b)  Professional. — The  professional  examination  embraces 
both  written  and  oral  examinations,  and  clinical  work,  as  fol- 
lows : 

Written : 

Anatomy,  physiology,  and  histology. 
Materia  medica  and  therapeutics. 
Pathology  and  bacteriology,  dental. 
Chemistry,  physics  and  metallurgy. 

Oral : 

( )ral  surgery. 
Operative  dentistry. 
Prosthetic  dentistry. 

Clinical  work : 

Operative. 
Prosthetic. 

An  average  of  75  per  cent  is  required  in  the  subjects  of  the 
theoretical  examination  and  85  per  cent  in  the  practical  exam- 
ination. 

The  questions  in  the  several  subjects  are  furnished  to  the 
boards  by  the  Surgeon  General.  A  sample  list  of  questions  is 
appended. 

All  instruments  and  materials  used  at  examinations  are  fur- 
nished by  the  Government. 

An  applicant  failing  in  one  examination  may  be  allowed  an- 
other after  the  expiration  of  one  year,  but  not  a  third.  With- 
drawal from  examination  during  its  progress,  except  for  sickness, 
will  be  deemed  a  failure. 

Appointment 

Applicants  who  qualify  are  appointed  dental  surgeons  accord- 
ing to  the  needs  of  the  service  during  the  ensuing  year,  in  the 
order  of  their  standing  at  the  examinations.  After  the  expira- 
tion of  a  year  they  will  no  longer  be  considered  eligible  until 
again  examined. 

The  appointments  are  made  upon  the  recommendation  of  the 
Surgeon  General,  by  the  President  of  the  United  States,  by  and 
with  the  advice  and  consent  of  the  Senate,  and  the  rank  of  first 
lieutenant  immediately  attaches  thereto. 


THE  DENTAL  CORPS,  U.  S.  ARMY    463 


Pay  and  Emoluments 

To  each  commissioned  rank  in  the  Army  is  attached  a  fixed 
annual  salary,  which  is  received  in  monthly  payments,  and  this 
is  increased  by  10  per  cent  for  each  period  of  .">  years'  service 
until  a  maximum  of  40  per  cent  is  reached.  A  dental  surgeon 
with  the  rank  of  first  lieutenant  receives  $2,000  per  annum,  or 
$166. GO  monthly,  during-  his  first  5  years'  service.  At  the  end  of 
.")  years  his  annual  pay  is  increased  to  $2,200,  or  $183.33  a  month. 
At  the  end  of  S  years  he  is  advanced  to  captain  and  receives 
$2,100  a  year,  plus  10  per  cent  of  his  first  5  years'  service, 
making  $2,640,  or  $220  a  month ;  and  thereafter  his  annual  pay 
is— at  the  end  of  10  years,  $2,880,  or  $240  a  month;  at  the  end 
of  15  years,  $3,120,  or  $260  a  month;  at  the  end  of  20  years, 
$3,360,  or  $280  a  month.  At  the  end  of  24  years  he  is  advanced 
to  major  and  receives  $4,000  a  year,  that  being  the  pay  of  his 
grade,  $3,000  plus  increase  for  prior  service  of  20  years  up  to 
$4,000,  which  is  the  maximum  allowed  by  law  to  a  major.  Offi- 
cers, in  addition  to  their  pay  proper,  are  furnished  with  a  liberal 
allowance  of  quarter's  according  to  rank,  either  in  kind,  or, 
where  no  suitable  Government  building  is  available,  by  commu- 
tation. Fuel  and  light  therefor  are  also  provided.  When  trav- 
eling on  duty  an  officer  receives  mileage  for  the  distance  trav- 
eled. On  change  of  station  he  is  entitled  to  transportation  of 
professional  books  and  papers  and  a  reasonable  amount  of  bag- 
gage at  Government  expense.  Groceries  and  other  articles  for 
their  own  use  may  be  purchased  from  the  quartermaster  at  about 
wholesale  cost  prices.  Well-selected  professional  libraries  are  sup- 
plied to  each  hospital,  and  standard  modern  publications  on  med- 
ical and  surgical  subjects,  including  dental  journals,  are  added 
from  time  to  time.  Dental  surgeons  are  entitled  to  medical  at- 
tendance and  hospital  treatment  without  charge  other  than  for 
subsistence. 

Privileges 

Leave  of  absence  on  full  pay  may  be  allowed  at  the  discretion 
of  the  proper  authority  at  the  rate  of  one  month  per  year,  which 
may  accumulate  to  a  maximum  of  four  months,  and  at  the  end 
of  four  years  is  then  available  as  one  continuous  leave.  Beyond 
this  an  officer  may  still  be  absent  with  permission  on  half  pay. 
Absence   from  duty  on  account   of  sickness  involves  no  loss  of 

pay. 


464     HISTORY  OF  MILITARY  DENTAL  LAWS 

Officers  of  the  Denial  Corps  are  entitled  to  the  privilege  of 
retirement  after  40  years'  service,  or  at  any  time  for  disability 
incurred  in  the  line  of  duly.  On  attaining'  the  age  of  64  they 
are  placed  on  the  retired  list  by  operation  of  law.  Ketired  offi- 
cers receive  three-fourths  of  the  pay  of  their  rank  (salary  and 
increase)    at  the  time  of  retirement. 

Assignment,  Duties,  Etc. 

Officers  of  the  Dental  Corps  are  not  permanently  assigned  to 
any  regiment  or  arm  of  the  service.  They  are  assigned  to  duty 
upon  the  recommendation  of  the  Surgeon  General  *or  of  the 
department  surgeon  of  a  territorial  department.  No  choice  of 
station  can  be  accorded  or  promise  made  of  assignment  to  any 
specified  locality. 

When  an  officer  of  the  Dental  Corps  reports  for  duty  at  a 
post  or  station  a  suitable  operating  room  will  be  provided  for 
him,  in  the  hospital  if  a  room  is  available  there,  otherwise  in  one 
of  the  other  post  buildings.  All  instruments,  appliances,  and 
materials  necessary  to  the  performance  of  his  duties  are  sup- 
plied by  the  Government.  Ordinarily  one  enlisted  man  of  the 
Medical  Department  will  be  detailed  to  assist  in  operations, 
in  caring  for  public  property  and  stores,  and  in  the  perform- 
ance of  clerical  work. 

Officers  of  the  Dental  Corps  serve  free  of  charge  all  those 
entitled  to  free  medical  treatment  bv  medical  officers. 


WAR    DEPARTMENT 

Office  of  the  Surgeon  General 

The  next  examination  will  be  held 

There  are  now  Vacancies  in  the  Dental  Corps  of 

the  Army. 

EXAMPLES    OF   WRITTEN   QUESTIONS 
Anatomy,  Physiology,  and  Histology 

1.  Name  the  cranial  nerves  and  their  functions. 

2.  (a)   What  is  the  Gasserian  ganglion? 

(b)  Where  is  it  situated? 

(c)  What  is  its  function? 

3.  What  structures  pass  through  the  foramen  magnum? 


THE  DENTAL  CORPS,  U.  S.  ARMY         465 

4.  Name  the  functions  of  the  red  and  white  blood  corpuscles, 
and  state  number  of  each  in  a  cubic  millimeter. 

5.  Describe  the  first,  second  and  seventh  bones  of  the  ver- 
tebral column. 

G.     What    conditions   may   prevent    putrefaction   in   dead   or- 
ganism .' 

7.  Describe  the  mechanism  whereby  the  heart  tissue  is  nour- 
ished. 

8.  Name  the  principal   tissues  of  the  animal  body. 

9.  State  the  functions   of   the  epithelium. 

10.     Describe    the    salivary    glands;    their    number,    structure, 
names,  location,  functions,  and  ducts. 

Materia  Medica  and  Therapeutics 

1.  (a)   For  what   purpose  is  arsenotrioxidum  used  in  dental 
surgei  y  ? 

(b)  What  are  its  effects  on  soft  tissue? 

2.  (a)  State  the  difference   between   fixed   and   volatile  oils. 
(b)  Give  two  examples  of  each. 

3.  (a)  Describe  the  physiological  action  of  amyl  nitrite, 
(b)  State  dose  and  method  of  administering  it. 

4.  What   are  the  dental   uses  of:   pyrozone  solutions?  ethyl 
chlorid  ? 

5.  (a)   What   is  an   alterative?     Name  two,   and   state  dose 
of  each. 

(b)   Name   two  mineral  and  two  vegetable  astringents. 
G.     From  what  are  the  following  drugs  derived:  tannic  acid? 
Monsel's  solution?  ether?  ethyl  alcohol? 

7.  What   are  the  advantages  and  disadvantages  of  local   as 
compared  with  general  anesthesia  for  extraction  of  teeth? 

8.  Give  doses  of  the  following  drugs:  Pepsin,  aromatic  spir- 
its of  ammonia,  potassium  iodid,  codein,  phosphate  of  sodium. 

9.  Write  a  prescription  for  a  dentifrice,  in  both  metric  and 
apothecary  systems. 

10.  Name  four  derivatives  of  opium.     Give  dose  of  each. 

Pathology  and  Bacteriology,  Dental 

1.  What  is  an  exostosis?     Where  does  it  ordinarily  occur  in 
or  near  the  oral  cavity? 

2.  What  is  a  sanguinary  or  serumal  calculus?     Of  what  is 
it  composed  and  where  is  it  found? 

3.  Differentiate  between   congestion    and   acute  inflammation 
of  the  cinirivae. 


466     EISTORY  OF  MILITARY   DENTAL  LAWS 

4.  What  is  septicemia,  and  what  causes  it?  Describe  its 
symptoms. 

5.  What  is  meant  by  fermentation?  What  kind  of  fermen- 
tation is  of  special  interest   to  dentists.' 

G.  What  effects  may  be  produced  in  the  mouth  from  the  ad- 
ministering of  large  doses  of  calomel?  Name  the  condition  and 
describe  it. 

7.  Are  there  any  objections  to  the  use  of  hot  applications 
externally  in  the  treatment  of  dento-alveolar  abscess"?  If  so, 
give  them. 

8.  What  are  bacteria  ?  In  what  forms  do  they  occur?  Give 
an  example  of  a  pathogenic  bacterium  of  each  form. 

9.  What  is  a  ptomain?    A  toxin?     A  virus? 

10.  What  pathogenic  organisms  may  be  concerned  in  dis- 
eases of  the  mouth  and  throat? 

Chemistry,  Physics,  and  Metallurgy 

1.  What  is  aqua  regia?    What  is  its  chief  property? 

2.  Name  the  four  most  important  elements  found  in  the  hu- 
man body. 

3.  Describe  the  chemical  changes  that  occur  in  the  process 
of  bleaching. 

4.  How  is   plant    life   sustained? 

5.  Mention  the  principal  constituents  of  atmospheric  air,  and 
state  the  proportions  in  which  these  constituents  are  present. 

6.  Describe  a  method  of  refining  gold  scraps. 

7.  How  can  the  specific  gravity  of  a  body  lighter  than  water 
be  determined? 

S.  How  would  you  distinguish  chemically  between  oxychlorid 
of  zinc  and  oxj'phosphate  of  zinc? 

9.  Give  the  chemical  symbols  of  glacial  phosphoric  acid 
(metaphosphoric  acid);  chloroform;  hydrogen  sulphid;  anti- 
mony; arsenious  acid. 

10.  Describe  the  process  of  converting  1  dwt.  of  22  k.  gold 
plate  into  18  k.  gold  solder. 

EXAMPLES  OF  ORAL  QUESTIONS 

Oral  Surgery 

1.  What  three  forces  are  applied  in  the  extraction  of  teeth? 

2.  Give  the  local  and  the  constitutional  causes  of  non-union 
of  fractures. 


THE  DENTAL  CORPS,  U.  S.  ARMY         467 

3.  How  are  the  after-pains  of  tooth  extraction  treated? 

4.  Stale  your  treatment  of  a  fracture  of  the  jaw,  through  the 
symphysis. 

5.  What  constitutional  effects  are  caused  by  a  severe  hem- 
orrhage? 

.  6.  State  the  indications  for  trephining  the  antrum.  Describe 
the  operation. 

7.  What  is  pyorrhea  alveolaris?  State  the  latest  theory  of 
treatment. 

S.     How  may  general  infection  be  caused  by  oral  operation? 

9.  What  diseases  of  the  tongue  may  be  mistaken  for  car- 
cinoma ? 

10.  Differentiate  between  fracture  and  dislocation  of  the  man- 
dibular condyle. 

Operative  Dentistry 

1.  How  are  cavities  classified? 

2.  Give  your  treatment  of  a  lower  molar  in  which  the  nerve 
is  alive  in  anterior  canal  and  putrescent  in  posterior  canal. 

3.  Give  diagnosis  and  treatment  of  irritation  from  pulp 
stones. 

1.  State  your  method  of  restoring  a  fractured  central, — frac- 
ture extending  below  gingival  margin,  root  being  sound. 

5.  What  is  a  dental  matrix? 

6.  Describe  your  operation  for  removing  a  live  pulp  from  a 
left  upper  sound  cuspid,  the  tooth  to  be  used  as  an  abutment 
for  bridge  work. 

7.  Describe  Dr.  Buckley's  treatment  for  putrescent  pulps. 

8.  Is  immediate  root  canal  filling  advisable  after  extraction 
of  nerve  under  pressure  anesthesia?  If  so,  state  your  method 
of  operation. 

9.  State  causes  necessitating  root  amputation.  Describe  the 
operation. 

10.  State  your  method  of  sterilizing  instruments. 

Prosthetic  Dentistry 

1.  How  would  you  bridge  a  case  replacing  the  right  superior 
cenh'al  incisor? 

2.  Suggest  three  teeth  with  cavities  where  you  would  insert 
gold  inlays. 

3.  Describe  your  method  of  obtaining  model,  investing  and 
casting  a  gold  inlay. 


468     HISTORY  OF  MILITARY  DENTAL  LAWS 

I.  In  bridge  work,  posterior  to  first  bicuspid,  should  the 
teeth  Jit  the  gum  perfectly,  or  should  a  space  be  left  between 
the  gum  and  the  bridge?     Explain. 

5.  State-  your  method  of  making  a  gold  crown  for  a  molar 
tooth,  giving  carat  and  gauge  of  gold  used. 

(i.  Stale  your  method  of  repairing  a  broken  porcelain  fac- 
ing on  an  anterior  bridge  in  mouth. 

7.  In  soldering  a  small  piece  of  gold  to  a  large  piece,  on 
which  should  the  solder  be  placed?    Why? 

8.  Describe  the  method  of  constructing  a  handed  Logan 
cuspid  crown. 

!).  What  class  of  cavities  indicates  the  use  of  synthetical 
porcelain?  State  advantages  and  disadvantages  of  the  porce- 
lain. 

10.  Describe  an  appliance  for  expanding  or  enlarging  the 
arch. 

SCOPE  OF  THE  PRACTICAL   EXAMINATION 

The  examining  board  exercises  its  judgment  in  selecting  the 
tests  according  to  the  time  and  clinical  material  available. 

Operative 

Examination  of  the  oral  cavity,  and  diagnosis  of  pathological 
conditions  found. 

Extraction  of  roots  of  broken-down  teeth. 

Adjusting  porcelain  crown,  cast   base,  or  grinding. 

Gold  filling;  compound  filling;  compound  amalgam  filling; 
oxyphosphate  filling. 

Treatment  of  exposed  pulps  and  putrescent  root  canals. 

Prophylactic   treatment. 

Prosthetic 

Taking  impressions  of  mouth,  running  models,  mounting  on 
articulator,  and  articulating  teeth. 

Making  gold  crown,  or  gold  and  porcelain  crown,  or  gold 
and  porcelain  bridge. 

Great  praise  should  be  given  to  the  patriotic  efforts 
and  results  obtained  by  the  Preparedness  League  of 
American  Dentists,  whose  work  in  banding  together  the 
dental  profession  throughout  the  country  has  been  highly 


PREPAREDNESS  LEAGUE  OF  DENTISTS    469 

commendable.  This  committee  is  now  composed  of  such 
estimable  dentists  as  Dr.  Edward  C.  Kirk,  Philadelphia, 
Pa.,  Chairman;  Dr.  Frederick  B.  Moorehead,  Chicago, 
111.;  Dr.  G.  V.  I.  Brown,  Milwaukee,  Wis.;  Dr.  J.  W. 
Beach,  Buffalo,  N.  Y. ;  Dr.  Herbert  L.  AVheeler,  New 
York,  N.  Y. ;  Dr.  Weston  A.  Price,  Cleveland,  Ohio ;  Dr. 
W.  H.  G.  Logan,  Chicago,  111.;  Dr.  Harvey  Burkhart, 
Rochester,  N.  Y. 

The  Journal  of  (he  National  Dental  Association,  Vol- 
ume IV,  Number  Eight,  August,  1917,  prints  the  follow- 
ing announcement : 

PREPAREDNESS    LEAGUE    OF    AMERICAN    DENTISTS 

J.  W.  Beach,  Chairman 

Buffalo,  N.  Y. 

The  Preparedness  League  of  American  Dentists  has  become 
the  medium  through  which  the  dental  profession  at  large  is 
carrying  on  the  work  or  preparation  for  the  great  service  that 
is  ahead  of  it.  For  a  year  and  a  half  this  organization  has  been 
putting  forth  every  effort  to  awaken  our  profession  to  the  reali- 
zation of  the  situation  and  had  it  not  been  for  the  unceasing 
labor  of  the  organizers  of  the  League  surely  we  would  have 
found  ourselves  in  a  deplorable  state  of  unpreparedness  when 
the  stirring  message  that  "War  is  upon  us"  was  sounded  from 
coast  to  coast. 

The  League  has  nearly  6000  active  members  and  more  than 
125  Sectional  Units  in  active  operation.  Study  courses  are 
planned  for  these  Units  and  several  lectures  with  slides  are  fur- 
nished free  of  charge.  This  has  proven  a  most  effective  means 
of  preparing  hundreds  of  our  members  for  the  entrance  exam- 
inations to  the  Officers  Reserve  Corps.  Dental  Section.  We  are 
gratified  to  report  satisfactory  progress  in  securing  a  splendid 
Dental  Reserve  for  our  Government  and  we  predict  the  estab- 
lishment of  the  most  efficient  service  in  this  important  depart- 
ment of  any  nation. 

Caring  for  the  mouths  of  applicants  for  enlistment  who  are 
unable  to  pay  for  dental  service  is  a  most  important  object  of 
the  League  and  we  wish  to  take  this  opportunity  to  thank  our 
members  for  the   unparalleled   response  this  phase  of  our  work 


470     ITTSTORY  OF  MILITARY  DENTAL  LAWS 

lias  received.  We  arc  proud  of  our  profession  and  when  the 
final  reckoning  shall  come,  it  will  be  shown  that  we  have  saved 
our  country  many  thousands  of  fighters.  The  League  has  been 
designated  the  official  medium  for  prosecuting  this  work  and 
members  are  requested  to  report  to  our  headquarters  all  cases 
thus  cared  for  so  that  we  may  compile  statistics  to  present  to 
the  Surgeon  General.  The  Government  appreciates  what  we  are 
doing  and  we  believe  our  efforts  will  not  go  unrewarded  when 
future  favorable  legislation  may  be  desired  by  us. 

We  hope  to  bring  many  new  members  into  the  National 
Dental  Association  through  the  League  and  would  call  the  at- 
tention of  the  Officers  of  our  Units  to  this  matter.  We  should 
bring  many  into  the  National  before  the  annual  meeting  in 
October  next. 

The  second  annual  meeting  of  the  League  will  be  held  in 
conjunction  with  the  National  Dental  Association  on  October 
23rd,  1M17,  in  Concert  Hall,  Hotel  Astor,  New  York.  We  are 
planning  a  splendid  program  and  will  be  able  to  report  won- 
derful results  from  the  different  Units.  Several  dental  ambu- 
lances for  use  in  France  are  being  supplied  by  our  Units  and 
other  equally  patriotic  movements  are  under  way. 

We  urge  the  formation  of  Units  more  generally  in  order  to 
promote  the  various  objects  of  the  League.  Organization  is 
essential  and  we  would  point  out  that  now  is  the  time  our  best 
efforts  are  demanded,  as  the  League  is  organized  as  a  war  meas- 
ure, therefore  Ave  invite  correspondence  with  this  object  in  view. 
Headquarters  are  at  131  Allen  St.,  Buffalo,  N.  Y. 

You  May  Win   the  War 

by  caring  for  a  single  mouth !  Stranger  things  have  happened 
in  the  world's  history.  We  would,  therefore,  impress  you  with 
your  individual  importance  at  this  critical  time  when  our  great 
service  to  humanity  has  established  pre-eminence. 

Dentistry  is  marching  to  its  own  under  the  triumphal  banner 
of  unselfish  service  to  the  great  army  of  our  young  manhood 
going  forth  to  fight  for  their  country. 

The  Report  of  Committee  on  Conservation  of  Prac- 
tices of  Enlisted  Dentists  introduced  in  the  Colorado 
State  Dental  Association  indicates  the  altruistic  motives 
of  the  dental  profession. 

The    Journal    of    the    National    Dental    Association, 


PREPAREDNESS  LEAGUE  OF  DENTISTS     471 

Volume  IV,  Number  Seven,  July,  1917,  quotes  the  fol- 
lowing: 

WAR   NOTES 

Report  of  Committee  ox  Conservation  of  Practices  of 
Enlisted  Dentists 

To  the  Colorado  State  Dental  Association : 

Your  committee  begs  to  submit  the  following  resolutions  as 
its  report. 

Whereas :  The  United  States  of  America  is  at  war  and  the 
efficiency  of  its  army  and  comfort  and  health  of  the  enlisted 
men  are  greatly  increased  by  dental  service,  and 

Whereas :  The  members  of  the  dental  professional  are  show- 
ing and  will  continue  to  show  their  love  of  country  and  fellow 
man  by  enlisting  in  large  numbers,  and 

Whereas :  Such  enlistment  entails  great  service  not  only  in 
the  hardships  and  hazard  of  service  but  in  the  loss  of  practice 
and  deprivation  of  dependent  ones  of  the  usual  necessities  and 
comforts  of  life,  and 

Whereas :  The  greatest  service  to  our  country  demands  that 
many  members  of  our  profession  shall  stay  at  home  and  con- 
tinue in  their  usual  rounds  of  duties,  and 

Whereas:  It  is  possible  for  those  members  of  the  profession 
who  do  stay  at  home  to  tender  special  service  to  their  country, 
their  profession  and  their  fellow  men  by  helping  to  conserve 
the  practices  and  care  for  the  dependent  ones  of  those  members 
of  the  profession  who  enlist  in  active  service,  and 

Whereas :  The  men  who  enlist  in  active  service  are  giving 
their  all  for  us  and  are  therefore  entitled  to  all  the  consider- 
ation and  help  of  those  who  remain  at  home,  it  must  be  con- 
sidered that  the  sen-ices  rendered  under  the  provisions  of  these 
resolutions  are  for  value  received  and  are  not  in  any  way  acts 
of  charity  nor  are  the  enlisted  men  or  their  dependent  ones  to 
consider  such  services  in  the  light  of  charity,  be  it  therefore 

Resolved :  That  this  society  appoint,  by  the  rules  governing 
the  appointment  of  members  to  the  state  board  of  dental  ex- 
aminers, a  committee  of  three  to  be  known  as  the  War  Com- 
mittee, and  that  the  duties  of  this  committee  shall  be  to  have 
general  supervision  of  the  conservation  of  practices  of  enlisted 
dentists  and  care  of  those  dependent  upon  them  under  and  gov- 
erned by  the  provisions  of  these  resolutions,  of  which  this  is  a 


472     HISTORY  OF  MILITARY  DENTAL  LAWS 

part.  That  this  committee  shall  have  the  power  to  appoint  three 
sub-committees  of  three  members  each,  and  that  these  sub-com- 
mittees shall  be  appointed  from  and  have  jurisdiction  over  the 
three  districts  of  the  Educational  Association  of  this  state  and 
the  boundaries  of  the  said  districts  of  the  educational  associa- 
tion shall  be  the  boundaries  of  the  districts  of  the  three  sub- 
committees appointed  under  this  resolution,  and  that  these  sub- 
committees shall  be  governed  and  directed  by  the  War  Commit- 
tee as  herein  provided.     Be  it  further 

Resolved:  That  any  dentist  who  is  about  to  enlist  may  notify 
the  War  Committee  to  that  effect  either  directly  or  through  the 
sub-committee  of  the  district  in  which  he  resides  and  that  the 
War  Committee  shall  then  submit  to  the  said  man  either  directly 
or  through  the  sub-committee  aforesaid  a  question  blank  sub- 
stantially as  follows : 

1.  How  old  are  you? 

2.  Married  or  single? 

3.  State  relation  and  age  of  any  who  are  dependent,  wholly 
or  in  part,  on  you  for  support,  and  if  in  part  state  proportion. 

4.  Do  you  feel  that  the  pay  you  will  receive  from  the  Gov- 
ernment will  be  sufficient  to  properly  care  for  those  dependent 
on  you,  and  if  not  what  amount  do  you  feel  would  be  necessary 
to  make  up  the  deficiency? 

5.  Do  you  wish  the  help  of  this  society  in  conserving  your 
practice  until  your  return  from  war? 

G.  Do  you  wish  the  help  of  this  society,  through  the  volun- 
tary service  of  its  members,  in  caring  for  your  patients,  to  aid 
in  the  care  of  your  dependent  ones,  and, 

7.  If  you  do,  what  per  cent  of  the  gross  receipts  for  such 
work  do  you  think  would  suffice  to  make  up  any  deficiency  of 
your  salary  in  the  care  of  your  dependent  ones? 

8.  What  are  the  gross  receipts  from  your  practice? 

9.  What  are  your  average  net  receipts? 

10.  If  you  desire  the  help  of  this  society  in  conserving  your 
practice  or  the  voluntary  aid  of  its  members  in  helping  to  care 
for  your  dependent  ones  through  services  rendered  to  your  pa- 
tients, will  you  submit  to  the  committee  a  list  of  your  patients 
with   their   latest   addresses? 

Upon  the  receipt  of  the  question  blank  properly  filled  out 
and  a  list  of  patients  accompanying  it,  it  shall  be  the  duty  of 
the  War  Committee  to  send  a  form  letter  to  each  person  on  the 
list,  the  letter  to  be  substantially  as  follows: 


PREPAREDNESS  LEAGUE  OF  DENTISTS     473 

Mr.  John  Doe,  13  Blank  St.,  City. 

Dear  Sir:  The  Colorado  State  Den- 
tal Association  is  doing  everything  in 
its  power  to  conserve  the  practices  and 
care  for  the  dependent  ones  of  those 
dentists  who  enlist  in  their  country's 
service  during  the  war. 

The  undersigned  committee  is  ap- 
pointed to  look  after  this  matter  and 
is  addressing  this  letter  to  you  in   the 

interest  of  the  practice  of  Dr. ,  who 

has  enlisted  for  active  service. 

Inasmuch  as  Dr.  has  been  serv- 
ing you  recently  in  a  professional  ca- 
pacity, we  are  asking  you  if  you  will 
consider  yourself  a   regular  patient  of 

Dr.  and   will    return   to   him   as  a 

patient    should    he    again    take    up    his 
practice  ? 

In  the  meantime  will  you  further  as- 
sist us  in  this  work  by  informing  who- 
ever you  maj*  go  *o  for  dental  services 

that  you  are  a  patient  of  Dr.  and 

are  so  listed  with  this  committee? 

You  will  undoubtedly  be  glad  to  as- 
sist your  country  and  her  loyal  defend- 
ers to  this  extent  and  we  thank  you  now 
for  mailing  your  reply  to  us  in  the  en- 
closed envelope. 

Cordially  yours, 

Committee. 

The  committee  shall  also  notify  the  members  of  the  profes- 
sion in  the  district  where  the  dentist  resides  who  is  about  to 
enlist,  of  the  fact  that  he  wishes  the  help  of  the  society. 

Be  it  further  resolved  that  the  members  of  this  society  who 
shall  voluntarily  agree  to  the  provisions  of  these  resolutions, 
shall  do  the  work  for  the  patients  of  the  enlisted  men  accord- 
ing to  the  lists  submitted  by  said  enlisted  men  and  agreed  to  by 
the  patients  themselves,  and  shall  turn  to  the  "War  Commit- 
tee or  sub-committee  that  per  cent  of  the  gross  receipts  of  such 
work  as  may  appear  necessary  to  properly  care  for  the  de- 
pendent ones  of  said  enlisted  dentists  according  to  the  infor- 
mation in  the  hands  of  the  War  Committee,  but  that  in  no  case 


474     HISTORY  OF  MILITARY  DENTAL  LAWS 

shall  the  dentists  doing  such  work  be  asked  or  expected  to  turn 
to  the  War  Committee  more  than  30  per  cent  of  the  gross  receipts 
of  said  work,  nor  shall  they  be  asked  or  expected  to  do  work 
for  said  patients  of  such  enlisted  men  in  amount  to  exceed  20 
per  cent  of  their  total  average  annual  practice. 

That  the  War  Committee  shall  devise  a  special  and  standard 
system  of  bookkeeping  for  every  phase  and  branch  of  this  work. 
Be  it  further  Resolved :  That  the  expenses  of  the  said  War 
Committee,  such  as  stenographer,  stationery,  stamps,  auditing, 
etc.,  be  raised  by  voluntary  subscriptions  of  the  members  of  this 
society. 

Signed:  G.  R.  Warner, 
H.  A.  Flynn, 

Committee. 

The  above  information  relative  to  the  Army  Dental 
Corps  has  been  selected  from  a  great  mass  of  dental  leg- 
islation. There  is  much  more  of  a  similar  nature  but  in 
the  author's  opinion  the  above  excerpts  include  all  that 
would  be  of  most  interest  to  readers  of  this  book. 

The  first  real  test  of  patriotism  has  been  met  by  the 
dental  profession  in  a  manner  far  exceeding  the  expecta- 
tions of  even  the  most  sanguine  dentist.  The  response 
to  the  cry  of  preparedness  has  penetrated  into  the  far- 
thest corner  of  professional  indifference.  Dentists  who 
were  formerly  apparently  dead  to  professional  pride 
have  burst  forth  into  a  fervor  of  patriotic  effort  unsur- 
passed even  by  their  medical  confreres.  No  longer  are 
dentists  looked  upon  as  individualists,  but  rather  as  spe- 
cialist members  of  the  great  mother  body,  medicine. 
Few  among  the  masses  appreciated  the  wonderful  strides 
made  by  dentistry  in  the  last  twenty  years.  Many  now 
are  awakened  to  the  wonderful  power  wielded  for  the 
good  of  humanity  by  men  dentally  trained. 

From  the.  European  hospitals  we  hear  frequent  reports 
of  the  invaluable  services  rendered  by  the  pioneer  dentists 
in  the  armies  of  the  Allies.  What  was  previously  looked 
upon  as  a  fad  is  now  appreciated  as  a  dire  necessity. 
Wounds  of  the  most  horrible  type,  jaws  shot  away,  whole 


PREPAREDNESS  LEAGUE  OF  DENTISTS     475 

faces  disfigured  by  shrapnel,  have  been  treated  and  re- 
stored to  usefulness  by  the  dental  profession.  The  mere 
mechanic  of  twenty  years  ago  is  today  recognized  as 
the  skilled  facial  surgeon.  The  general  surgeon  admits 
his  inability  to  compete  with  the  dental  specialist  in  face 
deformities.  American  dentists  have  thus  gained  long 
deserved  recognition  from  the  medical  profession  by 
their  wonderful  surgical  results  in  Europe. 

At  home  hundreds  of  dentists  are  entering  the  service. 
Hundreds  more,  unable  to  enter  active  service,  are 
banded  together  with  one  aim  in  view: — to  conserve  the 
efficienc}^  of  our  soldiers. 

The  future  will  place  the  dental  profession  side  by  side 
with  the  medical  profession  as  a  science  whose  aims  are 
humanitarian,  and  whose  efforts  are  unselfish  and  a  most 
useful  cog  in  the  wheel  of  progressive  civilization.  When- 
ever humanity  calls,  dentistry  has  not  been,  and  never 
will  be,  unresponsive  to  her  needs. 

Army  legislation  is  needed,  which  will  place  dentistry 
on  the  same  basis  as  medicine.  A  special  dental  corps 
should  be  created  distinct  from  medical  supervision,  with 
a  dental  surgeon  general,  colonels,  majors,  sufficient  in 
number  to  form  an  efficient  organization,  governed  by 
men  who  appreciate  the  oral  needs  of  the  enlisted  men 
and  whose  knowledge  of  dentistry  fits  them  to  command 
and  supervise  their  own  professional  brothers.  Misplaced 
medical  supervision  has  done  great  harm.  Even  the  best 
men,  medically  trained,  are  incompetent  to  supervise  den- 
tists. Dentists  know  what  they  need  and  what  our  en- 
listed men  require.  They  should  have  unlimited  control 
and  supervision  of  the  dental  corps.  Moreover  the  time 
is  at  hand  when  they  will  demand  and  should  receive  this 
right. 


INDEX 


Absqess,     apical,     extraction     of 
teeth  for,  23S. 
of  nasal  septum,  364. 
peritonsillar,   simulating'   syphi- 
lis, 359. 
Acapnia,  in  anesthesia,  309. 

complicating    surgery,    dangers 
of,  151. 
Acetanilid,   nature   and   effect   of, 

140. 
Acetate  of  lead,  141. 
Acetphenetidin,    140. 
Acetyl  salicylic  acid,  140. 
Acidosis,     complicating     surgery, 
152. 
dangers  of,  151. 
incidence  of,  153. 
treatment  of,  154. 
Acids  and  alkalies,  balance  of,  in 

surgery,  152. 
Adrenalin,     effect     of,     on     blood 
composition,  87. 
contradictory,  86. 
in  fatigue,  86. 
source  of,  86. 
Age,  determination  of  dosage  by, 

129. 
Alcohol,   nature  and   use   of,   144. 
Alimentary  canal,  esophagus,  73. 
mouth,  67. 
pharynx,  72. 
Alkali   diet,    excess,   in    treatment 

of  acidosis,  154. 
Alkalies,     administration     of,     in 
acidosis,  154. 
and   acids,   balance   of,   in   sur- 
gery, 152. 


Alum,  141. 
Alveolar  process,  26. 
cleft  of,  10. 
examination  of,  240. 
fractures  of,  271. 
Alveolodental  periosteum,  78. 
Amebic  theory  of  pyorrhea,  105. 
Analgesics,  in  neuralgia,  139. 

opium,  137. 
Anesthesia,  acapnia  in,  309. 
administration    of,    chloroform, 
306. 
ether,  305. 

exclusion  of  air,  303. 
gas,  304. 

gas  inhaling,  304. 
metal  face  piece,  304. 
apnea  in,  306. 
causes  of,  307. 
origin  of  symptoms,  30S. 
Sylvester's   method    of   artifi- 
cial respiration,  307. 
death  rates  from  gas,  ether  and 

chloroform,  302. 
hemorrhage  in,  308. 
history  of,  chloroform,  300. 
ether,  299. 
gas,  299. 
local,  145. 

for   maxillary   fractures,   surgi- 
cal, local,  208. 
novocain  and  suprarenin,  208. 
proper      care      in      injection, 

208. 
regulation    of    bowels    neces- 
sary, 210. 
technic  of  injection,  209. 


477 


478 


INDE1X 


Anesthesia,   necessity   for  care  in 
administration       of, 
158. 
physiology  of,  301. 
preparation     of     patients     for, 
emptying1  of  viscera, 
300. 
morphin     as    a    preliminary, 
301. 
rebreathing  in,  309. 
shock  in,  308. 
Anesthetics,     comparative     safety 
of,  302. 
local,  cocain,  146. 
ethyl  chlorid,  145. 
novocain,  148. 
Angle   apparatus,   for  mechanical 

fractures,  189. 
Antisepsis,  286. 
Antiseptic,  definition  of,  143. 
Antiseptics,  use  of,  143. 
Antrum  of  Highmore,  27. 
operation  on,  367. 
Denker,  368. 
indications  for,  367. 
Luc  Caldwell,  368. 
Apical  abscess,   incurable,  extrac- 
tion of  teeth  for,  238. 
roots   with,   extraction   of  teeth 
for,  238. 
Apnea,  in  anesthesia,  306. 
causes  of,  307. 
origin  of  symptoms,  308. 
Sylvester's    method    of    arti- 
ficial respiration  for, 
307. 
Apothecaries'  weight,  136. 
Arachnoid,  of  spinal  cord,  52. 
Army  dentist,  necessary  informa- 
tion   for,    See   Mili- 
tary Administration. 
Arsenic,  142. 

Arteries,    supplying    salivary 
glands,  71. 


Artificial    respiration,    Svlvester's 
method    of,    for   ap- 
nea, 307. 
Asepsis,  286. 

oral,  agents  for,  143. 
problem  of,  143. 

sterilization,  287. 
Aspirin,  140. 
Asthenic   conditions,   complicating 

surgery,  157. 
Astringents,  acetate  of  lead,  141. 

action  of,  141. 

alum,  141. 

arsenic,  142. 

caustics  or  escharotics,  142. 

classes  of,  141. 

krameria,  142. 

lactic  acid,  142. 

oak  bark,  142. 

silver  nitrate,  142. 

tannic  acid,  141. 

witch  hazel,  142. 
Atresias,  causes  of,  8. 


Bacteriological     experiments,     on 

dental  caries,  111. 
Balance  of  acids   and   alkalies  in 

surgery,  152. 
Bandages,  application  of,  294. 
of  head,  Barton's,  297. 
figure-of-eight,  295. 

of  both  eyes  or  binocular, 

296. 
of    one    eye    or    monocular 
band,  296. 
four-tailed,  296. 
Gibson's,  298. 
horizontal  circular,  295. 
recurrent  or  melon,  296. 
materials  for,  295. 
for     maxillary     fractures,    me- 
chanical, application 
of,  192. 


TXDEX 


479 


Bandages,  for  maxillary  fractures, 
Barton,   193. 
four-tailed,  192. 
Bands,    for    maxillary    fractures, 

188. 
Barton's  bandage,  297. 
Bedding  roll,  for  military  service, 

411. 
Beriberi,  vitamines  and,  90. 
Bichlond  of  mercury,  144. 
Bicuspid,  deformity  of,  266. 
extraction  of  roots  of,  262. 
first,     maxillary     fractures    be- 
tween    cuspid     and, 
231. 
removal  of,  254. 
Blood,  amount  of,  in  brain,  during 
sleep,  96. 
fitting  of,  for  unusual  muscular 
exertion   by   adrena- 
lin, 87. 
Blood  composition,  action  of  ad- 
renalin on,  87. 
Blood  pressure,  action  on,  by  an- 
esthesia with  nitrous 
oxid  and  oxygen,  98. 
action  on,  of  emotions,  100. 
depression   of,  by  epiphysis  or 

pineal  gland,  S8. 
lessening   of,    in    brain,    during 

sleep,  96. 
method    of    making    relatively 
"continuous"  records 
of,  98. 
recent  advances  in  study  of,  98. 
Bone  metabolism,  relation  of  para- 
thyroids to,  87. 
relation  of  pituitary  to,  88. 
Bones,  cranial,  ethmoid,  20. 
frontal,  15. 
occipital,  19. 
parietal,   16. 
sphenoid,  22. 
temporal,  17. 


Bones,  facial,  malar  bone,  28. 

lacrimal,  29. 

of  lower  jaw,  31. 

nasal,  30. 

palate  bone,  27. 

superior  maxilla,  25. 

turbinates,  29. 

vomer,  30. 
wormian,  33. 
Boric  acid,  as  disinfectant,  144. 
Brain,  anatomy  of,  54. 

cerebellum,  57. 

cerebral  hemispheres,  57. 

cerebrum,  55. 

fissures,  58. 

fourth  ventricle,  56. 

ganglia,  59. 

interbrain,  60. 

lobes  of  brain,  57. 

medulla  oblongata,  55. 

midbrain,  60. 

pons  Varolii,  56. 

ventricles,  59. 
arachnoid,  54. 
divisions  of,  54. 

dura  mater,  diaphragma  sellae, 
54. 

falx  cerebelli,  54. 

falx  cerebri,  53. 

tentorium  cerebelli,  53. 
fissures  of.  58. 
ganglia  of,  59. 
lobes  of,  57. 
location  of,  53. 

nerves  of,  See  Nerves,  cranial. 
pia  mater,  54. 
ventricles  of,  59. 
weight  of,  54. 

white  matter  of,  groups  of,  60. 
Brain  cortex,  action  of,  92. 

as  an  inhibitory  organ,  92. 
Breathing,    improper,    or    mouth- 
breathing,  causes  of, 
371. 


4S0 


[NDEX 


Breathing,  proper,  necessity  of, to 
health,  370. 

( lalcium,  in  the  formation  of  tar- 
tar, 104. 

Calorie  intake,  in  convalescence, 
post-operative,   L62. 

Calvaria,  38. 

Canals,  metallic -silver  impregna- 
tion of,  1 15. 

Cancer,  unerupted  teeth  mistaken 
for,  266. 

Cannon's  theory  of  surgical  shock, 
L59. 

Carcinoma  of  tongue  or  mouth, 
simulating  syphilis, 
358. 

Cardiac  conditions,  complicating 
surgery,  15G. 

Carotid  arteries,  origin  and  course 
of,  81. 

Cascara,  in  post-operative  cathar- 
sis, 161. 

Cataphoresis,  definition  of,  395. 
process  of,  395. 

Catharsis,  post-operative,  161. 
prior     to     surgical     operations, 
156. 

Caustics,  142. 

Cavities,  sterilization  of,  115. 

Cementum  of  teeth,  78. 

Cerebellum,  57. 

Cerebral   hemispheres,   fissures  of 
brain,  58. 
ganglia  of  brain,  59. 
lobes  of  brain,  57. 
ventricles  of  brain,  59. 

Cerebrum,  55. 

"Chalones,"  86. 

Chest  measure,  for  military  serv- 
ice, 402. 

Chin-pieces,  for  maxillary  frac- 
tures, mechanical, 
194. 


Chloroform,     administration     of, 
30G. 

death  rates  from,  302. 

history  of,  300. 
( Christian   Science,  124. 

Clefts,  of  alveolar  process,  10. 

causes  of,  7. 
facial,   oblique,  13. 

transverse,  14. 
harelip,  0. 

median,  of  lower  lip,  lower  jaw, 
and  tongue,  14. 
of  upper  lip,  12. 
nasal,  lateral,  12. 
of  palate,  11. 
Coal-tar  series,  139. 
acetanilid,  140. 
aspirin,  140. 
phenacetin,  140. 
Coca    plant,    effects    and    use    of, 
14G. 
as  local  anesthetic,  147. 
Cocain,  aseptic  precautions  in  use 
of,  148. 
danger     in     administration     of, 

147. 
disadvantages  of,  148. 
effects  of,  147. 
modus  operandi  of  injection  of, 

149. 
origin  of,  14G. 

and  novocain,  pharmacology  of, 
145. 
Coeain  poisoning,  aseptic  precau- 
tions against,  148. 
validol  in  treatment  of,  148. 
Colloid,   relation   of,   to   tooth-an- 

abolism,  87. 
Condyloid   fracture,  treatment   of, 

218. 
Convalescent  care,  post-operative, 
caloric  intake,  1G2. 
intake    of    fluids    and    solids, 
162. 


INDEX 


481 


Cranial  nerves.    See  Nerves,  cra- 
nial. 
Cranium,   bones   of.      See    Bonos, 

cranial. 
Creosote,  144. 
Crile's    work    on    surgical    shock, 

159. 
Croup,  diphtheritic,  3S8. 
Cuspids,    extraction    of    roots    of, 
261. 
maxillary      fractures      between 
first     bicuspid     and, 
231. 
removal  of,  254. 
Cystic  odontomata,  326. 
dental  root  cysts,  326. 

incidence  of,  327. 
diagnosis  of,  by  roentgen  rays, 

331. 
follicular  cysts,   327. 
occurrence  of,  328. 
signs  of,  329. 
multilocular  cysts,  330. 
exciting  cause  of,  331. 
Cysts,  dental  root,  326. 
follicular,  327. 
multilocular,  330. 

Dakin's  solution,  294. 
Deformities,  of  bicuspid,  266. 
of  molar,  lower  third,  267. 
unerupted  teeth,  266. 
Denker  operation  on  antrum,  368. 
Dental    abscess,    and   focal   infec- 
tion, 107. 
as  responsible  for  systemic  dis- 
eases, 103,  105,  107. 
treatment     of,     metallic     silver 
impregnation   of  ca- 
nals, 115. 
Dental    caries,   bacteriological   ex- 
periments on,  111. 
clinical  study  of,  114. 
Goadby's  work  on,  109. 


Dental  caries,   Kleigler's  work  on, 
110. 
and    metallic    silver    impregna- 
tion of  canals,  115. 
Miller's  work  on,  108,  113. 
Moro-Tissier    group    of    organ- 
isms of,  111. 
and  Moro's  acidophilus,  114. 
and     sterilization     of     cavities, 
115. 
Dental  laws,  military.     See  Mili- 
tary Dental  Laws. 
Dental    profession,    legislation    to 
place,  on  same  basis 
as  medical,  475. 
patriotic   services   rendered   by, 
474. 
Dental  pulp,  7S. 

lymphatic  system  of,  78. 
Dental   Keserve    Corps    Surgeons, 
necessary      informa- 
tion  for.      See   Mili- 
tary Administration. 
Dental  root  cysts,  326. 
Dental  surgery  and  technic,  cata- 
phoresLs,  395. 
recent  advances  in,  cataphoresis, 
395. 
desensitizing  dentin,  399. 
elements  of  electrolysis,  392. 
ionization,  395. 
Dental  work  and  military  roentge- 
nology,  310. 
Dentifrices,  liquid,  145. 
tooth  pastes,  145. 
tooth  powders,  dangers  of,  144. 
Dentin,  77. 
Dentinal  tubuli,  77. 
Dentist,  army,  necessary  informa- 
tion for.     See  Mili- 
tary Administration. 
Dentistry,  electricity  in.  See  Elec- 
tricity in  Dentistry. 
Desensitizing  dentin,  399. 


482 


IX  DUX 


Diabetes,     complicating     surgery, 

156. 
Diet,  post-operative,  in  distention 
with  gas,  1G1. 
early  nutrition,  160. 
in  paresis  of  bowel,  161. 
prior    to    surgical    operations, 
155. 
Dietetics,  advances  in,  90. 
I  Hgestive  system,  67. 
alimentary  canal,  esophagus,  73. 
mouth,  67. 
pharynx,  72. 
function  of,  73. 
muscular  tube  of,  73. 
oral  cavity  beginning  of,  68,  74. 
salivary  glands,  71. 
Diphtheria,  diagnosis  of,  385. 
differentiated     from     Vincent's 

angina,  389. 
nasal,  387. 
O'Dwyer    intubation     tube     in, 

389. 
organism  of,  Klebs-Loeffler  ba- 
cillus, 385. 
simulating  syphilis,  360. 
symptoms  of,  386. 
tracheotomy  in,  mortality  from, 

390. 
transmission  of,  386. 
Diphtheritic  croup,  388. 
Disinfectants,  alcohol,  144. 
bichlorid  of  mercury,   144. 
boric  acid,  144. 
creosote,  144. 
definition  of,  143. 
hydrogen  peroxid,  143. 
iodin,  144. 
phenol,  143. 
Dislocation,     and     roentgenology, 

335. 
Distention    of    bowels    with    gas, 
post-operative,     diet 
in,  161. 


Drainage,  289. 

indications  for,  290. 
types  of,  289. 
Dressing  of  wounds,  294. 
Dakin's  solution,  294. 
wet  dressing,  294. 
Dressings,  materials  for,  289. 
Drooling,   in   maxillary   fractures, 
surgical,      treatment 
of,  211. 
Drugs,  action  of,  118. 
administration  of,  127. 
means  of,  127. 

through     the     mucous     mem- 
brane, 128. 
through  the  skin,  128. 
time  for,  128. 
analgesics,  coal-tar  series,  139. 

opium,  137. 
astringents,  141. 

acetate  of  lead,  141. 
alum,  141. 
arsenic,  142. 

caustics  or  escharotics,  142. 
krameria,  142. 
lactic  acid,  142. 
oak  bark,  142. 
silver  nitrate,  142. 
tannic  acid,  141. 
witch  hazel,  142. 
coal-tar  series,  139. 
acetanilid,  140. 
aspirin,  140. 
phenacetin,  140. 
dentifrices,  144. 

determination  of  dosage  by  age, 
129. 
by  weight,  129. 
disinfectants,  143. 
alcohol,  144. 

bichlorid  of  mercury,  144. 
boric  acid,  144. 
creosote,  144. 
hydrogen  peroxid,   143. 


INDEX 


483 


Drugs,  disinfectants,  iodin,  144. 
phenol,  143. 
general  effects  of,  IIS. 
prescriptions  of,  126. 

methods  of  measuring,  127. 
toleration  to,  128. 
dangers  of,  129. 
Dry  socket,  273. 

Ductless    glands,    adrenal    glands, 
86. 
epiphysis  or  pineal  gland,  88. 
hypophyseal  or  pituitary  body, 

88. 
of  ovary  and  testis,  S8. 
pancreas,  89. 
parathyroids,  87. 
physiological  researches  on,  85. 
thymus,  89. 
thyroid,  S7. 
Dura  mater,  of  spinal  cord,  52. 
Dynamic  theories,  relating  to  mus- 
cular function,  97. 


Electricity    in     dentistry,     acidity 
a  n  d     alkalinity     at 
poles,  394. 
cataphoresis,  395. 
elements  of  electrolysis,  392. 
ionization,  395. 
ions,  dh-ection  of,  394. 
Electrolysis,  definition  of,  394. 
elements  of,  392. 
amperage,  392. 
resistance,  393. 
voltage,  392. 
processes  of,  cataphoresis,  395. 
ionization,  395. 
Elevator's,    for   removal    of   roots, 
bicuspid,      Coolidge, 
262. 
incisor,  straight  spoon,  261. 
for   extraction    of   teeth,    blades 
of,  244. 


Elevators,  for  extraction  of  teeth, 
Lecluse's,     or     lower 
wisdom  or  third  mo- 
lar elevator,  259. 
obtuse-angle,  244. 
right-angle  or  Coolidge,  243. 
straight,  243. 
Emotions,    action     of,     on    blood 

pressure,  100. 
Empirical  therapeutics,  120. 
Enamel  of  teeth,  77. 
Epiphysis,    relation    of,    to    blood 

pressure,  88. 
Epistaxis,  362. 

control  of,  363. 
Escharotics,  142. 
Esophagus,  location  of,  73. 
Ether,   administration   of,  danger- 
ous    symptoms     in, 
306. 
methods  of,  305. 
death  rates  from,  302. 
history  of,  299. 
Ethmoid,  20. 
Ethyl  chlorid,  145. 
Examination,  of  alveolar  process, 
240. 
of  gums,  240. 
of  todth  structure,  239. 
Extraction  of  teeth,  23S. 
accidents  common  in,  279. 
dropping  of  tooth,  272. 
fractures,  of  alveolar  process, 
271. 
of  the  teeth,  271. 
hemorrhage,  272. 
after  treatment  of,  273. 

for  dry  socket,  273. 
in  deformities,  of  bicuspid,  266. 
of  molar,  lower  third,  267. 
unerupted  teeth.  266,  267. 
examination,  of  mouth  for,  239 
of  alveolar  process,  240. 
of  condition   of  gums,  240. 


4S4 


1X1  )KX 


Ixtraction   of   teeth,   examination 
of    tooth    structure, 
239. 
impacted,  2(f). 
instrumentation  for,  240. 
elevators,  blades  of,  244. 
Lecluse's,  or  lower  wisdom 
or  third  molar  eleva- 
tor, 259. 
obtuse-angle,  244. 
right-angle     or     Coolidge, 

243. 
straight,  243. 
forceps,  beaks,  forms  of,  241. 
handles  of,  242. 
special,  241. 
removal  of  roots,  260. 
various  instruments,  243. 
misplaced,  265. 

operative  procedure  for,  anato- 
my of  jaws  in,  245. 
bicuspids,  254,  255. 
chair,  245. 

choice  of  surface,  250. 
cuspids,  254. 
grasping  the  tooth,  250. 
hand  grasp,  247. 
incisors,  252. 
laterals,  253. 
loosening  of  tooth,  251. 
molar,  255. 
lower,  257. 
lower  third,  250. 
upper,  255. 
operator  and   patient,  246. 
position  of  operator,  245. 
removal,  252. 
removal  of  roots,  260. 
bicuspid,  262. 
cuspid,   261. 
incisor,   261. 
instruments  for,  260. 
molar,  lower,  264. 
molars,  upper,  263. 


Extraction  of  teeth,  operative  pro- 
cedure for,  stages  of 
technic,  250. 
reasons     for,     incurable     apical 
abscess,  238. 
insecure  roots,  238. 
pyorrhea,  238. 

roots  with  apical  abscess,  238. 
sound   but    useless   teeth,  239. 
supernumerary   teeth,  238. 
types  of,  requiring,  241. 
Eyelids,  muscles  of,  40. 

Face,  bones  of.    See  Bones,  facial. 
congenital    deformities    of,    af- 
fecting frontal  plate, 
9. 

cleft  of  alveolar  process,  10. 

cleft  palate,  11. 

groups  of,  8. 

harelip,  9. 

involving  first  visceral  arch, 
14. 

median  clefts  of  lower  lip, 
lower  jaw  and 
tongue,   14. 

median  clefts  and  notches  of 
upper  lip,  12. 

nasal   clefts,   lateral,   12. 

oblique  facial  clefts,  13. 

transverse  facial  clefts,  14. 
development   of,   alteimate   con- 
formation of  face,  4. 

frontal  process,  3. 

intermaxillary   bone,    6. 

oral   pit,  1. 

oral   plate,  1. 

palate,   6. 

superior  maxillary  process,  2. 

teeth,  7. 

tongue,  7. 

visceral  arches,  1. 
muscles    of.       See    Muscles    of 
Face. 


IXPEX 


485 


Fat   emboli,   as  cause  of  surgical 

shock,   160. 
Fatigue,  adrenalin  in   relation  to, 

86. 
Feeding,    in    maxillary    fractures, 

surgical,  20G. 
First    aid     packet,     for    military 

service,  409. 
Fistulous  tract,  insertion  of  wick 

in,  teclmic  of,  223. 
Fixation,   in    treatment   of   maxil- 
lary fractures,  179. 
Flat  feet,  military  exemption  for, 

404. 
Fluid     intake,     in     convalescence, 
post-operative,  162. 
Focal    infectidff,    and    dental    ab- 
scess, 107. 
and  pyorrhea,  107. 
Follicular  cysts,  327. 
Forceps,   for  extraction   of  roots, 
260. 
cuspid,  261. 
molar,  264. 
for  extraction   of   teeth,   beaks, 
forms  of,  241. 
handles,  242. 
method  of  grasping,  247. 
special,  241. 
Foreign    bodies,    removal    of,    in 
fractures,  204. 
time  for,  205. 
Fossa,  anterioi-,  36. 
middle,  37. 
posterior,  37. 
nasal,  38. 
Fourth  ventricle,  56. 
Fractures,  of  alveolar  process,  in 
extraction    of    teeth, 
271. 
for  army  dentist,  332. 
of  lower  jaw,  333. 
of  upper  jaw,  332. 
comminuted,  197. 


Fractures,  complicated,  197. 
compound.  197. 
greenstick,  197. 
impacted,  197. 
maxillary.  See        Maxillary 

Fractures. 
in  military  life,  203. 
multiple,   197. 
of  nasal  bones,  302. 
simple,  197. 

of  teeth,  in  extracting,  271. 
of   upper   jaw.     See   Maxillary 
Fractures    of    upper 
jaw. 
Frontal  bone,  15. 
Frontal  plate,  congenital  deform- 
ities affecting,  9. 
Frontal   process,   development   of, 
3. 

Gas,  administration  of,  304. 
death  rates  from,  302. 
formation      of,      post-operative. 

diet  in,  161. 
history  of,  299. 
(las  inhaling,  in  administration  of 

anesthesia,   304. 
Gasserian    ganglion    injection    of 

novocain,  2S3. 
Geographic      tongue,      simulating 

syphilis,   358. 
German  measles,  381. 
Germicide,  definition  of,  143. 
Gibson's  bandage,  298. 
Glands,   adrenal,  86. 

duct  loss.     See  Ductless  Glands, 
hypophyseal  or  pituitary  body, 

88. 
pancreas,  89. 
parathyroid,  87. 
pineal,  or  epiphysis,  88. 
salivary.     See  Salivary  Glands, 
thymus,  89. 
thyroid,   87. 


486 


TNDEX 


Goadby,  wink  of,  on  dental  caries, 
1(1!). 

Gums,  examination  of  condition 
of,  240. 

Gunshot  wounds,  and  roentgenol- 
ogy, 335. 


Hamamelis,  1  12. 

Harelip,  0. 

Hartel's  teehnic,  283. 

Head,  muscles  of.    See  Muscles  of 
Head. 

Heart,   military    requirements   re- 
garding, 403. 

Height,     required,     for     military 
sei'vice,  402. 

Hematoma      of      nasal      septum, 
304. 

Hemorrhage,  in  anesthesia,  symp- 
toms of,  308. 
in  extracting  of  teeth,  272. 
in  maxillary  fractures,  surgical, 
factors  inducing, 

226. 
treatment   of,   226. 
from   nose.     See   Epistaxis. 
from    "wounds,    291. 

Hernia,    military    exemption    for, 
403. 

Herpes  labialis,  simulating  syph- 
ilis, 357. 

Homeopathy,    practice   of,    123. 
principle   of,   122. 

Hormones,  86. 

Horse,  for  militaiy  service,  407. 
care  of,  40<S. 

Hutchinsonian     teeth,     in     hered- 
itary syphilis,  355. 

Hydrogen  peroxid,  143. 

Hyoid  bone,   muscles  of,  46. 

Hypertrophied   tonsils,   360. 

Hypophysis,  relation    of,   to   bone 
metabolism,   88. 


Impressions,  plaster,  181. 
taking    of,    in    maxillary    Erac 
tures,     surgical,     of 
upper  jaw,  207. 
for  splints,  181. 
articulation,   183. 
occlusion.    186. 
opening  the  kite,  186. 
packing  the  mold,   L85. 
perfection  of  model  essen- 
tial, 182. 
Incisors,    extraction    of    roots    of, 
261. 
removal  of,  252. 
Infection,  causes  of,  286. 
Infective  disease,  338. 

danger  of,  in  camps,  etc.,  376. 
prevalent  in  army,  339. 
diphtheria,  360,  385. 
hypertrophied  tonsils,  360. 
measles,  377. 
measles  and  mumps,  369. 
quinsy    or    peritonsillar    ab- 
scess, 359. 
reports  on,  435. 
scarlet  fever,  3S1. 
syphilis,   339. 
tonsillitis,   359. 
Vincent's  angina,  388. 
Inferior  maxillary  bone.     See  Jaw 

Bone. 
Infra-orbital    injections    of   novo- 
cain, 278. 
Injections    of    novocain,    anterior 
palatine,  281. 
gasserian  ganglion,  283. 
Hartel's  teehnic,  283. 
infra-orbital,  278. 
mandibular,  274. 
mental,  279. 
posterior  palatine,  281. 
zygomatic,  277. 
Instruments,     for     extraction     of 
roots,  elevators,  261. 


INDEX 


487 


Instruments,     for     extraction     of 
roots,  forceps,  200. 
for   extraction    of   teeth,    eleva- 
tors, 243. 
elevators,  259. 
forceps,   241. 
various,   243. 
Interbrain,   60. 
Interglobular  spaces,  78. 
Intermaxillary  bone,  development 

of,  6. 
Internal  secretions,  adrenalin,  86. 
ductless  glands,  85. 
of  epiphysis  or  pineal  gland,  88. 
hormones,  86. 
of    hypophyseal     or    pituitary 

body,  88. 
interrelation  of,  89. 
koliones  or  "chalones,"  86. 
of  ovary  and  testis,  88. 
of  pancreas,  S9. 
of  parathyroids,  87. 
probable,  89. 
of  thymus,  89. 
of  thyroid,  or  colloid,  87. 
Intubation  tube,  O'Dwyer,  3S9. 
Iodin,  form  and  use  of.  144. 

value  of,  in  oral  asepsis,  206. 
Ionization,  uses  of,  395. 

in   pyorrhea.      See   Pyorrhea, 
ionization    in    treat- 
ment of. 
in  sterilization  of  root  canals, 
397. 
Ions,  definition  of,  394. 

direction  of,  394. 
Irrigation,  in  maxillary  fractures, 
surgical.  207. 


Jaw,  lower,  fractures  of,  333. 
median  clefts  of,  14. 
upper,  fractures  of,  332. 
Jaw  bone,  lower,  31. 


Jaw  bone,  lower  body  of,  31. 

internal  surface  of,  31. 
Jaws,  anatomy  of,  for  extraction 

of  teeth,   245. 
Jugular  vein,  origin  of,  S4. 

Klebs-Loeffler  bacillus,  3S5. 
Kleigler,   work   of,   on   dental  ca- 
ries, 110. 
Koliones,  86. 
Krameria,  142. 

Lacrimal  bones,  29. 

Lactic  acid,  142. 

Laterals,  removal  of,  253. 

Laudanum,  137. 

Lead,  acetate  of,  141. 

Lecluse's  elevator,  259. 

avoiding  accidents  with,  260. 

Leukoplakia,  simulating  syphilis, 
358. 

Lip,   lower,  median  clefts  of,  14. 
upper,       median      clefts       and 
notches  of,  12. 

Local  anesthetics,  aromatic  oil 
series,   149. 

Luc  Caldwell  operation  on  an- 
trum, 368. 

Lungs,  ventilation  of,  aided  by 
skin,  94. 

Macrostoma,  14. 

Malar  bone,  28. 

Malar  process,  26. 

Mandible,  fracture  of.  See  Max- 
illary Fractures, 
surgical,  of  mandi- 
ble. 

Mandibular  injection  of  novocain, 
274. 

Mastication,  muscles  of,  43. 

Mastoid  portion  of  temporal 
bones,   17. 

Maxillae,  anatomy  of,  197. 


488 


INDEX 


Maxillary    fractures,    mechanical, 
treatment    of,    angle 
apparatus,  L89. 
bandages,    application    of, 

192. 
Barton,  193. 
four-tailed,   192. 
bauds,  188. 

bands  and  ligatures,  188. 
chin-pieces,  194. 
for  emergency  work,  188. 
medical,    with    displacement    of 
fragments,  176. 
forms  of,  174. 
multiple,  174. 

treatment    of,     bone     wiring, 
167. 
fixation,   179. 
history  of,  165. 
ligature  method,  167. 
primitive  methods,  166. 
special  appliances,  176. 
splints,    Bullock's    adapta- 
tion    of     Hayward, 
171. 
crib,   173. 
difficulties  of,  181. 
edentulous,    181. 
Hammond,  168. 
Harrison   Allen's,  172. 
Hayward,  170. 
interdental,  171,   180. 
interdentulous,    181. 
jacket,  180. 
Kingsley,  171. 
metal,   169. 
Moon,  169. 

taking  of  impression  for, 
181. 
articulation,    183. 
occlusion,  186. 
opening    of    the    bite, 

186. 
packing  the  mold,  185. 


Maxillary  fractures,  medical,  treat- 
ment of,  splints,  tak- 
ing of  impression 
for,     perfection     of 

model  essential,  182. 
plaster,  181. 
temporary,  ISO. 
types  of  appliances,  179. 
surgical,  and   anatomy  of  max- 
illae,   197. 
anesthesia  in,  after-pains  fol- 
lowing       injections, 
causes  of,  208. 
bowel  regulation  necessary, 

210. 
local,  208. 
novocain     and    suprarenin, 

208. 
proper    care    in    injection, 

208. 
technic  of  injection,  209. 
complete,   196. 

compound     fracture     in     one 
part    of    jaw,    with 
simple     fracture     in 
another,  228. 
condyloid,   treatment  of,  218. 
between   cuspid   and   first   bi- 
cuspid,  231. 
at  neck  of  condyle,  218. 
differentiated     from     dislo- 
cation, 218. 
diagnosis     of,     for     way     in 
which     tissues     have 
been   hit  by  projec- 
tile, 227. 
diagnosis  and  methods  of  ex- 
amination of,  202. 
in   military   life,   203. 
palpation,  202. 
feeding  in,  206. 
hemorrhage    in,     factors    in- 
ducing, 226. 
treatment    of,    226. 


INDEX 


489 


Maxillary    fractures,   surgical,   in- 
complete,  197. 
infection  in,  from  dead  pulps, 
202. 
points  of  involvement,  199. 
pus    formation,    causes    of, 

199. 
radiographs   for,   value   of, 

201. 

tetanus.  199,  228. 

irrigation  in,  207. 

of  mandible,  211,  232. 

at    angle    of,   213. 

typical  case  of,  211. 

in    military   life,  203. 

determination     of    way     in 
which     tissues     have 
been   hit   by   projec- 
tile,  227. 
oral    asepsis    in,    importance 
of,  204. 
maintaining  of,  205. 
value  of  iodin  in,  206. 
pathological,   danger  of,  221. 
radiographs     for,     value     of, 

201. 
reduction  and  fixation  of,  by 
wiring  of  teeth,  235. 
removing    foreign    bodies    in, 
204. 
time  for,  205. 
scope  of  chapter,  19G. 
study  of  recoil,  210. 
summary,  229. 
of  symphysis,  217. 
taking     of     impressions     in, 

207. 
treatment  of,  between  cuspid 
and     first     bicuspid, 
231. 
for  drooling,  211. 
external      incisions,      inser- 
tion of  wick,  technic 
of,  223. 


Maxillary  fractures,  surgical,  ex- 
ternal incision,  pre- 
vention of  point- 
ings and  drainage, 
222. 
radiographic  precautions, 

224. 
suturing    bone    with    me- 
tallic substances, 
225. 
treatment  of  scar,  224. 
triple  compound  fracture 
with  fistula,  222. 

between  first  and  third 
molars,  second  mo- 
lars missing,  233. 

for  hemorrhage,   220. 

importance  of  cleanliness 
in,  227. 

in   mandible,  232. 

main  points  in,  237. 

packing  of  wounds  in  the 
mouth,   224. 

practical  aspects  of,  229. 

reduction  and  maintaining 
fixation,  210. 

rest,  214. 

skull  cap,  214. 

splint  of  preference,  223. 

splints,  214. 
vulcanite  interdental, 

253. 

suturing  bone  with  metallic 
substances,   225. 

triple  compound  fracture 
with  fistula,  222. 

unerupted  malposed  third 
molar,  229. 

by  wiring  of  teeth,  for  re- 
duction and  fixation, 
235. 
triple  compound,  with  fistula, 

222. 
types  of,  197. 


490 


INDEX 


Maxillary   fractures,  surgical,  un- 
erupted        malposed 
third   molar  in,  229. 
of  upper  jaw,  L96. 

diagnostic   signs  of,   L98. 
symptoms  of,  197. 
where  teeth  are  missing,  216. 
Measles, 
degree  of  contagion  of,  37S. 
diagnostic   points  in,  379. 
essentia]   points   about,   3S0. 
German,  3S1. 
incidence  of,  377. 
prevalence  of,  in  army,  309. 
race   susceptibility   to,    377. 
symptoms  of,  378. 
infective  stage,  379. 
Koplik's  sign,  378. 
Measures,  weights  and,   130. 
Medical    care    of    patient    in    sur- 
gery,   in    anesthesia, 
158. 
complicating      conditions,      as- 
thenic, 157. 
cardiac,  150. 
diabetes,  150. 
nephritis,  150. 
general  condition,  acapnia,  151. 
acidosis,  dangers  of,  151. 
acidosis,  as  a  factor  in,  152. 
incidence  of,  153. 
treatment  of,  154. 
alkalies,      administration     of, 

154. 
balance  of  acids  and  alkalies, 

152. 
metabolism.  152. 
pre-operative     factors     in.     ca- 
tharsis, 156. 
complicating   conditions,   156. 
complicating     systemic      dis- 
eases, 150. 
diet,  155. 
general  condition,  151. 


Medical  care  of  patient  in  surgery, 
pre-operative  factors 
in,  psychic  prepara- 
tion, 155. 
pre-operative    and    post-opera- 
tive,    necessity     of, 
Mil. 
post-operative,  catharsis,  101. 
convalescent,  102. 
diet,    100. 

nausea  and  vomiting,  157. 
renal  irritation,  158. 
in  surgical  shock,  159. 
in   systemic   diseases   complicat- 
ing surgery,  chronic 
conditions,   150. 
Medulla  oblongata,  55. 
Mental   examination,   for  military 

service,   404. 
Mental  injection  of  novocain,  279. 
Metabolic  disease,  338. 
Metabolism,    consideration    of,    in 
surgery,  152. 
and  movements  of  villi  of  small 

intestine,  91. 
of    bone,    relation    of    pai'athy- 
roids  to,  87. 
See  Bone  Metabolism, 
of  sugar,  relation  of  pancreatic 
secretion  to,  S9. 
Metallic    silver    impregnation    of 
canals,  115. 
method  of  use  of,  110. 
solutions  necessary  for,  116. 
Metric   system,   130. 

and   apothecaries'  weight,  130. 
weights  and  measures,  130. 
Microorganisms,  present  in  pyor- 
rhea.  103. 
universal   prevalence  of,  105. 
of  dental  caries,  bacteriological 
experiments  on,  111. 
Goadby   on,  109. 
Kleigler  on,  110. 


INDEX 


491 


Microorganisms,   of  dental  caries, 
Miller  on,  108. 
Moro-Tissier  group  of,  111. 
Microstoma,  11. 
Midbrain,  60. 

Military  administration,  401. 
application  for  U.S.D.R.C.,  401. 
"Army    Regulations,"   copy   of, 
given  to  officers,  422. 
pertaining    to    dentist    as    an 
officer  of  army,  Ar- 
ticles of  War,  416. 
courts  and  offenses  coming 
under        jurisdiction 
of,  416. 
use  of  term  "officer,"  416. 
bathing,  412. 

blanks    in    preparation    of    re- 
ports    and     returns, 
425. 
appointment  form,  431. 
on  contagious  diseases,  435. 
dental  cards,  433. 
dental  supplies,  425. 
invoices,  428. 
items,  428. 
listed  outfit,  429. 
receipt  of  supplies,  427. 
requisitions,  for  blanks,   427. 
filling  of,  426. 
for  portable  outfit,  427. 
returns,  430. 
signing,  433. 

transferring  property,  428. 
books,  449. 

dress,  etiquette  of,  424. 
equipment,   basin    and   bathing, 
412. 
bed  sacks,  414. 
bedding  roll,  411. 
canvas  bucket,  414. 
field,  407. 

eating  utensils,  408. 
first  aid  packet,  409. 


Military      administration,      equip- 
ment,    field,     pistol, 
etc.,  409. 
saddle-bags,  408. 
field  glasses,  446. 
first  aid,  447. 
hat,  416. 
horse,  407. 

care  of,  408. 
identification    tag,    415. 
lantern,  414. 
leggings,  415. 
map  case,  446. 
mosquito  bar,  410. 
necessity  arising  for  elimini- 

nation    of,   414. 
obtained     from     Quartermas- 
ter's Department,  410. 
obtained  from  Ordnance  De- 
partment,   410. 
pistol,  447. 
poncho,  415. 
rubber  boots,  451. 
sanitary,  440. 
shelter  tent,  415. 
underwear,  415,  447,  448. 
uniform,  406. 

field    service,    445. 
payment  for,  406. 
field     service     equipment,     field 
glasses,  440. 
first  aid,  447. 
map  case,  446. 
pistols,  447. 
underwear,  447,   448. 
uniform,  445. 
field  service  regulations,  436. 
ambulance  line,  438. 
evacuation  hospitals,  440. 
field  hospitals,  439. 
firing  line,  437. 
general  sanitation,  441. 
non-combatants,  444. 
pensions,  440. 


492 


IXDKX 


Military  administration,  field  serv- 
ice  regulations,   Red 

Cross,    II"). 
sanitary  equipment,    1  If), 
service    in    camps,    444. 

I is,  423. 

mental  examination,  40  I. 
in  i  seel  Ian  eons       information, 
books,  440. 
saluting,  448. 
settling  in  quarters,  449. 
officers,   adjutant,  423. 
commissioned    and    non-com- 
missioned, 41G. 
field,  417. 

senior  medical,  423. 
physical     examination    and    re- 
quirements,  401. 
chest    measure,  402. 
flat   feet,  404. 
heart,  403. 
height,  402. 
hernia,  403. 
teeth,  403. 
'    vision,  402. 
weight,  402. 
salute,  424. 
saluting,  448. 
sanitation,  general,  441. 

commanding    officers    respon- 
sible   for    conditions 
under    their    com- 
mand,  442. 
contagion   in   camp,  441. 
sanitary  inspector,  443. 
settling  in  quarters,  449. 
traveling1.  423. 

typhoid  inoculation   for,  405. 
See  also  Military  Dental  Laws. 
Military   dental    laws,   application 
for     appointment, 
460. 
appointment,  4G2. 
assignments,  duties,  etc.,  404. 


Military    dental    laws,    constitution 
of  corps,    159. 
examinations,  4G0. 

examples     id'    oral     questions, 
operative     dentistry, 
467. 
oral  surgery,  466. 
prosthetic  dentistry,  4(i7. 
examples     of     written     ques- 
tions,     anatomy, 
physiology   and    his- 
tology,  464. 
chemistry,  physics  and  met- 
allurgy, 466. 
materia  medica   and   thera- 
peutics, 465. 
pathology  and  bacteriology, 
dental,  465. 
physical,  461. 
practical,  scope  of,  468. 
professional,  461. 
Extract   from   Act  of  Congress 
approved     February 
2,  1901,  453. 
Form  142,  Revised  July  2,  1913, 

454. 
Form    146,    Revised    Feb.    27, 

1917,  459. 
history  of,  453. 
pay  and   emoluments,  462. 
physical    examination    and    re- 
quirement, 461. 
Preparedness  League  of  Amer- 
ican Dentists,  468. 
Report  of  Committee  on  Con- 
servation    of     Prac- 
tices     of      Enlisted 
Dentists,  471. 
privileges,  463. 
qualifications,  460. 
Military  Medical  Department,  or- 
ganization  of,   453. 
Miller,  work  of,  on  dental  caries, 
108,  113. 


INDEX 


493 


Molar  teeth,  extraction  of,  255. 
lower.  257. 
lower  third,  259. 
upper,  255. 
extraction    of    roots    of,    lower, 
257. 
upper,  2(53. 
first  and  third,  second  missing, 
maxillary     fractures 
of,  233. 
lower  third,  deformities  of,  267. 
operative  procedure  for  re- 
moval of,  2G9. 
symptoms      accompanying, 
268. 
third,    unerupted    malposed,    in 
maxillary    fractures, 
229. 
Moro's  acidophilus,  114. 
Moro-Tissier  group  of  organisms, 
in  dental  caries,  111. 
Morphin,  as  a  preliminary  to  an- 
esthesia, 301. 
Mosquito   bar,   for   military   serv- 
ice, 410. 
Mouth,  asepsis  of,  in  surgery,  im- 
portance of,  204. 
cavity  of.     See  Oral  Cavity, 
cleansing  of,  by  dentifrices,  144. 
by  disinfectants,  143. 
in  surgical  operations,  205. 
definition  of,  07. 
diseases  of,  simulating  syphilis, 
carcinoma  of  tongue 
or  mouth,  358. 
diphtheria,  360. 
geographic  tongue  or  wander- 
ing rash,  358. 
herpes  labialis,  357. 
hypertrophied   tonsils,   360. 
leukoplakia,  358. 
quinsy    or    peritonsillar    ab- 
scess, 359. 
stomatitis,  357. 


Mouth,     diseases     of,     tonsillitis, 
359. 
tubercular  ulcers,  358. 
Vincent's  angina,  35S. 
examination    of,    for    extraction 

of  teeth,  239. 
glands   of,    or   salivary   glands, 
anatomy  of,  71. 
histology  of,  75. 
mucous  membrane  of,  74. 
muscles  of,  41. 
parts  of,  67,  68. 
roof  of,  or  palate,  68. 
syphilis    of.      See    Syphilis    of 

mouth, 
teeth,  72,  77. 
tongue,  69,  76. 
Mouth    and    throat    symptoms    of 
infective  diseases,  in 
diphtheria,   3S6. 
measles,  377. 
scarlet  fever,  381. 
in  Vincent's  angina,  3SS. 
Mouth-breathing,  causes  of,  371. 
Mucous  membrane,  administration 
of     drugs     through, 
128. 
Multilocular  cysts,  330. 
Mumps,   prevalence   of,   in   army. 

369. 
Muscles,     action     of,     all-or-none 
principle,  97. 
dispute  in  regard  to,  97. 
sthenophoric  index,  98. 
of  eyelids,  40. 

orbicularis  palpebrarum,  41. 
of  face,  of  ej^elids,  40. 
of  mouth,  41. 
of  nose,  41. 
of  head,  muscles  of  mastication, 
43. 
muscles  of  the  orbit,  42. 
superficial,    muscles    of   face, 
40. 


494 


INDEX 


Muscles,  of  head,  superficial,  mus- 
cles of  scalp,  40. 
platysma  myoides,    10. 
of  hyoid   bone,  digastric,  46. 
geniohyoid,  47. 
infrahyoid,  46. 
mylohyoid,  47. 
omohyoid,  40. 
sternohyoid,  46. 
sternothyroid,  46. 
stylohyoid,  47. 
suprahyoid,  46. 
thyrohyoid,  46. 
of  mastication,  43. 
buccinator,  44. 
external  pterygoid,  43. 
internal  pterygoid,  44. 
masseter,  43. 
temporal,  43. 
of  mouth,  41. 
buccinator,  41. 
orbicularis  oris,  41. 
zygomatieus  major,  41. 
zygomaticus  minor,  42. 
of  neck,  deep  lateral   and  pre- 
vertebral,    vertebro- 
costal, 50. 
vertebrocranial,  50. 
vertebral,  50. 
of  hyoid  bone,  46. 
of  pharynx,  48. 
of  soft  palate,  49. 
sternocleidomastoid,   45. 
of  tongue,  47. 
of  nose,  41. 
of  the  orbit,  42. 

inferior  oblique,  42. 

levator   palpebrae   superioris, 

42.      ■ 
nerve  supply  of,  42. 
recti,  42. 

superior  oblique,  42. 
of   pharynx,   inferior   constrict- 
or, 49. 


Muscles,  of  pharynx,  middle  con- 
strictor,   ID. 
palatopharyngeus,  49. 
stylopharyngeus,  49. 
superior  constrictor,  48. 
of  scalp,  of  external  ear,  40. 

occipitofrontalis,  40. 
of   soft    palate,    azygos    uvulae, 
49. 
innervation  of,  50. 
levator   palati,  49. 
palatoglossus,  49. 
palatopharyngeus,  49. 
tensor    palati,  50. 
of   tongue,   extrinsic,   geniohyo- 
id ossus,  47. 
hyoglossus,  47. 
palatoglossus,  47. 
styloglossus,  47. 
intrinsic,     inferior     lingualis, 
48. 
sternocleidomastoid,  48. 
superior  lingualis,  48. 
Muscular      function,      all-or-none 
principle,   97. 
dispute  in  regard  to,  97. 
sthenophorie  index,  98. 
Muscular  vigor,  relation  of  secre- 
tions   of    ovary    and 
testis  to,  88. 

Nasal  bone,  30. 

fracture  of,  362. 
Nasal  clefts,   lateral,  12. 
Nasal  diphtheria,  387. 
Nasal  fossae,  38. 

Nasal  operations,  on  antrum,  367. 
Nasal  process,  26. 
Nasal  septum,  hematoma  and  ab- 
scess of,  364. 
deviated,    as    cause    of    mouth 
breathing,  371. 
causes  of,  372. 
submucous  operation  for,  372. 


INDEX 


495 


Nasal      septum,      perforated,      in 

syphilis,  352. 
Nasal  sinuses,  365. 

x-ray   as   aid   in   diagnosis   and 
translumination       of 
diseases  of,  365. 
Nausea  and  vomiting,  post-opera- 
tive, 157. 
Neck,  anatomy  of,  79,  80. 
lateral  aspect  of,  79. 
muscles    of.      See    Muscles    of 

Neck. 
triangular  arrangement  of  mus- 
cles of,  78. 
vessels  of,   common   carotid   ar- 
tery,   81. 
external  and  internal  carotid 

arteries,  82. 
internal  jugular  vein,  84. 
Neoplasms,     destruction     of,     by 
nitric  acid,  142. 
by   trichloracetic  acid,  142. 
Nephritis,    complicating    surgery, 

156. 
Nerve  fibers,   unmedullated,  91. 
Nerves,      cranial,      auditory,      or 
eighth,   64. 
branches     of     communication 
of  seventh  nerve,  63. 
branches    of    distribution    of 

seventh  nerve,  63. 
branches   of   twelfth,   66. 
facial,  or  seventh,  63. 
glossopharyngeal,     or    ninth, 

64. 
hypoglossal,  or  twelfth,   65. 
inferior   maxillary   branch   of 

fifth   nerve,   63. 
laryngeal    branches    of    tenth 

nerve,    65. 
lingual     branches     of     ninth 

nerve,   64. 
motor  oeuli  or  third,  62. 
olfactory  or  first,  61. 


Nerves,  cranial,  ophthalmic  branch 
of  fifth  nerve,  62. 
optic,  or  second,  62. 
sixth,  63. 
spinal  accessory,  or  eleventh, 

65. 
superior  maxillary  branch  of 

fifth  nerve,  62. 
trifacial     or     trigeminus,     or 

fifth,   62. 
trochlear    or    patheticus,     or 

fourth,    62. 
vagus    or    pneumogastric,    or 
tenth,    84. 
spinal,   arrangement   of,   66. 
of  tongue,  70. 
Nervous     system,     central,     brain 
cortex,  92. 
mechanism    of,    described    by 

Dercum,  93. 
unmedullated  nerve  fibers  of, 
91. 
cerebrospinal,  51. 
brain,   53. 
spinal  cord,  51. 
sympathetic,  51. 
Neuralgia,   analgesics  in,   139. 
Nihilism,  in   therapeutics,  126. 
Nitrate  of  silver,  142. 
Nitric  acid,  142. 
Nose,  bumps  on,  363. 

hemorrhage    from.      See    Epis- 

taxio. 
injuries  and  diseases  of,  361. 
bumps  on,  363. 
epistaxis,  362. 
fracture      of      nasal      bones, 

362. 
hematoma  and  abscess  of  sep- 
tum, 364. 
rhinitis,  acute,  364. 
muscles  of,  41. 
saddleback,  due  to  syphilis,  353. 


496 


INDEX 


Nose,  ventilation  and  drainage  of, 
necessity   of  mainte- 
nance of,   375. 
Novocain,  advantages  of,  over  co- 
cain,  148. 

in      anesthesia     for     maxillary 
fractures,   208. 

and    cocain,    pharmacology    of, 
145. 

formula  for  solution  of,  for  ex- 
ternal use,  149. 

modus    operandi    of    injecting, 
149. 

strength  of  solutions  of,  149. 
Novocain  technique,  anterior  pal- 
atine injection,  281. 

gasserian     ganglion     injection, 
283. 

Hartel's,  283. 

infra-orbital   injection,   278. 

mandibular  injection,  274. 

mental  injection,  279. 

posterior  palatine  injection,  281. 

zygomatic  injection,  277. 

Oak  bark,  142. 

Obesity,  avoidance  of,  by  modern 

physiology,  91. 
Occipital  bone,  19. 
Odontoplastic  cells,  78. 
O'Dwyer  intubation  tube,  389. 
Opium,  alkaloid  of,  138. 

control  of  pain  by,  138. 

definition  of,  137. 

law  regarding  use  of,  137. 

objections  to  use  of,  139. 

physiological  action  of,  138. 

tincture  of,  137. 
Oral  asepsis,  agents  for,  143. 

problem  of,  143. 

in  surgery,  importance  of,  204. 
maintaining  of,  205. 
value  of  iodin  in,  206. 
Oral  cavity,  anatomy  of,  68. 


Oral  cavity,  mucous  membrane  of, 
74. 

salivary  glands  in,  74,  75. 

teeth  and  tongue  in,  74. 
Oral  pit,  development   of,  1. 
Oral  plate,  development  of,  1. 
Orbit,  muscles  of,  42. 
Organisms,   of  diphtheria,   385. 

of  syphilis,   342. 
Osteopathy,  125. 
Ovary,  internal  secretion  of,  88. 

Packing,    of    wounds    in    mouth, 

224. 
Pain,  definition  and  cause  of,  138. 

relief  of,  by  opium,  138. 
Palate,  clefts  of,  11. 

definition  and  anatomy  of,  68. 

formation  of,  6. 

perforated,      in      syphilis      of 

mouth,  352. 
soft,   muscles   of.     See  Muscles 
of  Soft  Palate. 
Palate  bone,  27. 
plates  of,  27. 
processes  of,  28. 
Palate  process,  27,  28. 
Palatine    injections    of    novocain, 

28 1 . 
Pancreas,  relation  of  secretion  of, 
to  sugar  metabolism, 
89. 
Parathyroids,     number     and     de- 
scription of,  87. 
relation    of,    to    metabolism    of 
bone,  87. 
Paresis   of  bowel,   post-operative, 

161. 
Parietal  bones,   16. 
Parotid  gland,  71,  369. 
Perforated  nasal  septum,  in  syph- 
ilis, 352. 
Perforated   palate,  in  syphilis  of 
mouth,  352. 


INDEX 


497 


Peritonsillar     abscess,     simulating: 

syphilis,  359. 
Peroxid  of  hydrogen,  143. 
Pharmacodynamics,   definition   of, 

127. 
Pharmacology,  analgesics,  137. 
coal-tar  series,  139. 
opium,  137. 
definition  of,  127. 
dentifrices,  144. 
disinfectants,  143. 
drugs,  action  of,  118. 
administration  of,  127. 
astringents,  141. 
general  effects  of,  118. 
prescriptions  of,  126. 
importance    of    knowledge    of, 

118. 
metric  system,  130. 
of  novocain  and  cocain,  145. 
prescription  writing-,  131. 
therapeutics,  empirical,  120. 

physical,  119. 
therapy,  schools  of,  120. 
Pharmacy,  definition  of,  128. 
Pharynx,    location    and    anatomy 
of,   72. 
muscles    of.      See    Muscles    of 

Pharynx. 
openings    communicating-     with 
neighboring-  cavities, 
72. 
Phenaeetin,  nature  of,  140. 
Phenol,  nature  and  use  of,  143. 
Physical   therapeutics,   119. 
Physiology,    recent    advances    in, 
relating-,      to      blood 
pressure,  98. 
to  central   nervous   system, 

91. 
to  dietetics,  90. 
to   dynamic   theories,   97. 
to    internal    secretions,    85. 
to  metabolism,  90. 


Physiology,  recent  advances  in,  re- 
lating,   to    muscular 
function,  97. 
to  obesity,  91. 
to  sleep,  96. 
to     vasomotor     mechanism, 

96. 
to  ventilation,  94. 
Pia  mater,  of  spinal  cord,  52. 
Pineal  gland,  relation  of,  to  blood 

pressure,  88. 
Pistol,    etc.,   for   military   service, 

409. 
Pituitary,    relation    of,    to    bone 

metabolism,  88. 
Pons  Varolii,  56. 
Porter's   work   on   surgical   shock, 

160. 
Preparedness  League  of  American 
Dentists,  46S. 
Report   of   Committee   on   Con- 
servation    of     Prac- 
tices     of      Enlisted 
Dentists,  471. 
Prescriptions,   126. 

methods  of  measuring,  127. 
Prescription  writing-,  131. 
apothecaries'  weight,  136. 
important  points  in,  136. 
metric    system,    130. 
model  for,  132. 
prescription   blanks,  131. 
standard  meter,  136. 
Protein,  rule  in  regard  to  use  of, 

90. 
Psychic   preparation   for  surgery, 

155. 
Pterygoid   processos,   24. 
Pulp,   dental.      See   Dental    Pulp, 
devitalization     of,     by     arsenic, 
142. 
Pulps,    dead,    infection    in    frac- 
tures due  to,  202. 


498 


IXDIvX 


Pulps,    treatment     of,    by    Bilver 
nitrate,  142. 

Pus  formation  in  fractures,  causes 

of,   1!)!). 
Pyorrhea,  amebic  theory  of,  105. 
as  a  bacterial  disease,  100. 
condition   resembling,    produced 
in    guinea    pigs    by 
diet,  104. 
etiology  of,  103. 
extraction  of  teetli   for,  238. 
and    focal   infection,  107. 
importance  of  resistance  to,  100. 
ionization  in,  39G. 
current,  398. 

and  desensitizing  dentin,  300. 
frequency  of  treatment,   39S. 
positive  results  of,  397. 
reinfection,  399. 
root  canals,  398. 
microorganisms       of,      strepto- 
coccus viridans,  100. 
organisms  found  in,  103. 
produced  locally,  104. 
as  responsible  for  systemic  dis- 
eases, 103,  105,  107. 
secondary   to    anomalous    meta- 
bolic condition,  104. 
and  tartar  formation,  104. 
treatment    of,    104. 


Quercus,  142. 

Quinsy,   simulating   syphilis,   359. 


Radiographic  precautions,  in 
maxillary  fractures, 
surgical,   224. 

Radiographs,  value  of,  for  frac- 
tures,   201. 

Rebreathing,  in  anesthesia,  309. 

Renal  irritation,  post-operative, 
158. 


Respiration,    artificial,    Sylvester's 
method  of,  in  apnea, 
307. 
Rhinitis,  acute,  304. 
Roentgenology,     in     army     cases, 
331. 
dental  work  and,  310. 
dislocation,  335. 
fractures,  332. 
gunshot   wounds,  335. 
dental,  application  of  rays,  322. 
dental  films,  322. 
plates,  323. 
position,  323. 
localization      methods,      Sutton, 
325. 
triangulation,   324. 
Roentgen  ray  apparatus,  influence 

machine,  317. 
Roentgen   Ray   Society,   terminol- 
ogy adopted  by,  312. 
Roentgen  ray  tubes,  Coolidge,  316. 
gas,  316. 
hydrogen,  316. 
improvement  in,  315. 
Roentgen-rays,  as  aid  in  diagnosis 
and    translurnination 
of  diseases  of  nasal 
sinuses,  365. 
in    diagnosis   of   cystic    odonto- 

mata,  331. 
discovery   of,  311. 
production  of,  314. 
properties    of,    invisibility     of, 
314. 
penetration,  313. 
protection  from,  321. 
necessity  of,  320. 
trochoscope,  321. 
source  of,  313. 
Root  canal,  78. 

sterilization    of,    by    ionization, 

397. 
treatment  of,  by  ionization,  398. 


INDEX 


499 


Roots,    with    apical    abscess,    ex- 
traction of  teeth  for, 
238. 
extraction  of,  bicuspids,  262. 
cuspids,  261. 
incisors,  261. 
instruments  for,  260. 
molars.   lower,  264. 
upper,  263. 
insecure,  extraction  of  teeth  for, 
238. 


Saddleback  nose,   due  to  syphilis, 

353. 
Saddle-bap's,  for  military  service, 

408. 
Saliva,  infection  of  syphilis  from, 

346. 
Salivary  glands,  cells  of,  75. 

change    in,    by    discharge   of 
secretion,    75. 
ducts  of,  76. 
parotid,  71. 
purpose  uf,   74. 
secretions  of,   mucous,   75. 

serous  or  albuminoid.   75. 
sublingual,  71. 
submaxillary,    71. 
variety  classed   under,  75. 
Scalp,  muscles  of,  40. 
Scarlet  fever,   ambulant   cases  of, 
3S4. 
cause  of,  3S1. 
character  of,  381. 
essential    diagnostic    points    in, 

382. 
incubation  period  of,  381. 
infective  discharges  in,  383. 
liability     to     complications     in, 

383. 
symptoms  of,  381. 
Sexual  apparatus,  relation  of  thy- 
mus gland  to,  89. 


Shock,    in    anesthesia,    symptoms 

of,  30S. 
Silver  nitrate,  142. 
Silver     impregnation     of     canals, 

115. 
Sinuses,   communicating  with   na- 
sal fossae,  39. 
Skin,     administration      of     drugs 
through,    128. 
physiological    advances   relating 

to,  94. 
ventilation   of  lungs,   aided  by, 
94. 
Skull,    anatomy   of,    '.'>-. 

anatomy  of,  nasal  fossae,  3S. 
temporo-maxillary       articula- 
tion, 39. 
anatomy  of  interior  of,  anterior 
fossa,  36. 
calvaria,  38. 
middle   fossa,   37. 
posterior  fossa,  37. 
anatomy    of    outer    surface    of, 
anterior  region,  33. 
lateral  region,  34. 
inferior  or  basilar  region,  35. 
superior  region,  .'54. 
bones   of.      See    Bones,    cranial, 

and  Bones,  facial, 
definition  of,   15. 
Skull    cap,    use    of,    in    maxillary 

fractures,  214. 
Sleep,  recent  advances  in  study  of, 

96. 
Soldier,  efficiency  of,  and  health, 

338. 
Solid     intake,     in     convalescence, 
post-operative,  162. 
Soie  throat,  diagnosis  of,  385. 
Sphenoid,   22. 
body  of,  22. 

greater  and  lesser  wings  of,  23. 
pterygoid  processes  of,  24. 
Spinal  cord,  central  canal  of,  53. 


500 


TNDEX 


Spinal  cord,  gray  and  white  mat- 
ter of,  52. 
lateral  portions  of,  52. 
location   and   extent    of,   51. 
posterior  column  of,  52. 
protecting  membranes  of,  52. 
size  and  outline  of,  52. 
Spinal  nerves,  arrangement  of,  66. 
Splints,    Bullock's    adaptation   of 
Ilayward,  171. 
crib,  173. 
difficulties  of,  181. 
edentulous,  181. 
Hammond,  168. 
Harrison   Allen's,  172. 
Hay  ward,  170. 
interdental,   171,  180. 
jacket,  ISO. 
Kingsley,  171. 
metal,  169. 
Moon,  169. 
of     preference,     in     maxillary 

fractures,  233. 
special  types  of,  176. 
taking  of  impression  for,  181. 
articulation,  183. 
occlusion,  186. 
opening  the  bite,  186. 
packing  the  mold,  185. 
perfection  of  model  essential, 

182. 
plaster,  181. 
use   of,   in   maxillary  fractures, 

surgical,  215. 
vulcanite  interdental,  in   maxil- 
lary fractures,  235. 
Sterilization,  methods  of,  287. 
of    root    canals,    by    ionization, 

397. 
technic  of,  2SS. 
Sterilization  of  cavities,  115. 
Sthenophoric  index,  98. 
Stitches,  types  of,  continuous  su- 
ture, 292. 


Stitches,  types  of,  interrupted  su- 
tures, 293. 
intracuticular,  293. 
subcuticular,    293. 
Stomatitis,  simulating  syphilis,  357. 
Streptococcus    viridans    infection, 
and    dental    abscess, 
100. 
and  pyorrhea,  106. 
Submaxillary  "lands,  309. 
Submucous    operation,    for    devi- 
ated   nasal    septum, 
372. 
Superior  maxilla,  25. 
body  of,  25. 
processes  of,  20. 
Superior    maxillary    process,    de- 
velopment  of,  2. 
Suprarenal  capsule,  80, 
Suprarenin,     in     anesthesia     for 
maxillary    fractures, 
surgical,  208. 
Surgery,     acapnia     complicating, 
dangers  of,  151. 
acidosis  complicating,  152. 
clangers  of,  151. 
incidence  of,  153. 
treatment  of,  154. 
anesthesia  in,  careful,  necessity 

for,  158. 
balance  of  acids  and  alkalies  in, 

152. 
complicating  conditions,  asthen- 
ic, 157. 
cardiac,  150. 
diabetes,  156. 
nephritis,  150. 
convalescent  care  in,  caloric  in- 
take,  102. 
intake    of    fluids    and    solids, 
162. 
dental,  recent  advances  in.     See 
Dental   Surgery  and 
Technic. 


INDEX 


501 


Surgery,  general  condition  of  pa- 
tient before,  151. 
medical  care  of  patients  in.   See 
Medical  Care  of  Pa- 
tients, 
metabolism  considered  in,  152. 
post-operative   care   in,    cathar- 
sis, 161. 
convalescent,  162. 
in  distention  with  gas,  161. 
nausea  and  vomiting,  157. 
renal  irritation,  158. 
post-operative    diet,    early    nu- 
trition, 160. 
in  paresis  of  bowel,  161. 
pre-operative  measures,  cathar- 
sis, 156. 
diet,  155. 
psychic  preparation  for,  155. 
systemic    diseases   complicating, 
chronic       conditions, 
150. 
Surgical    shock,    Cannon's    theory7 
of,  159. 
Crile's  work  on,  159. 
and  fat  emboli,  160. 
Porter's  work  on,  160. 
Surgical  technic,  antisepsis,  2S6. 
asepsis,  2S6. 

bandages,  application  of,  294. 
of  head,  Barton's,  297. 
figure-of-eight,  295. 
figure-of-eight  of  both  eyes 

or  binocular,  296. 
figure-of-eight    of    one    eye 
or   monocular   band, 
296. 
four-tailed.  296. 
Gibson's,  29S. 
horizontal  circular,  295. 
recurrent  or  melon,  296. 
material  for,  295. 
drainage,  2S9. 

indications  for,  290. 


Surgical    technic,   drainage,   types 
of,  289. 
dressing  of  wound,  294. 
Dakin's  solution,   294. 
wet  dressing,  294. 
in     hemorrhage    from    wounds, 

291. 
infection,  causes  of,  286. 
materials  for,  dressings,  289. 

sutures,   288. 
sterilization,  methods  of,  2S7. 

technic  of,  288. 
suturing    of    wounds,    approxi- 
mation of  parts,  291. 
types  of  stitch,  292. 
wounds,  clean,  290. 
septic,  291. 
Suture  materials,   2S8. 
Sutures  of  skull,  33. 
Suturing  of  wounds,   approxima- 
tion of  parts,  291. 
types   of  stitch,   continuous  su- 
ture, 292. 
interrupted  sutures,  293. 
intracuticular  stitches,  293. 
subcuticular,  293. 
Symphysis,  fractures  of,  217. 
Syphilis,  care  of  mouth  in,  351. 
course  of,  341. 
diagnosis    and    early    treatment 

of,  340/ 
diagnosis  positive,  before  begin- 
ning    of     treatment, 
356. 
diseases    of   mouth,    simulating. 
See   Mouth,   diseases 
of,  simulating  sj'ph- 
ilis. 
hereditary,  348. 

Hutchinsonian  teeth  in,  355. 
location  of  primary  sore  in,  341. 
manifested     in     nasal     sinuses, 

354. 
of  mouth,  care  of  mouth  in,  351. 


502 


INDEX 


Syphilis,    of    mouth,    forms    of, 
345. 
illustrated,  348. 
infection   from  saliva,  .">l(i. 
mucous  patches,  345. 
perforated   palate,  352. 
perforated   nasal    septum    in, 

352. 
points     especially     important 

to  dentists,  348. 
precautions    against,     to    be 
take  n    by    dentist, 
350. 
uvula  involved,  353. 
necessary  evidence  of,  355. 
organism  of,  342. 
habits   of,   348. 
prevalence  of,  in  army,  339. 
prevention  of,  340. 
reports  to  be   rendered   of  mu- 
cous patches,  435. 
results  of,  340. 
saddleback  nose  due  to,  353. 
and  salvarsan,  351. 
sources  of,  342. 
stages  of,  342. 
primary,  343. 
secondary,   343. 
tertiary,  347. 
symptoms  of,  lesions  of  mouth, 
314. 
parasyphilitis    348. 
primary,  343. 
secondary,  344. 
tertiary,   347. 
transmission  of,  342. 

from  saliva,  346. 
typical  scar  from,  353. 
complicating    surgery,     medical 
care    of    patient    in, 
150. 
Systemic  infection,  dental  abscess 
responsible  for,  103, 
105,  107. 


Systemic    infection,     pyorrhea    re- 
sponsible     for,     103, 
105. 
tartar  formation  as,  105. 

Tannic  acid,  141. 

'tartar,  formation  of,  104. 

nature    of,    104. 
Teeth,    deformities    of,    bicuspid, 
266. 
of  molar,  lower  third,  207. 
unerupted,  26G. 
development  of,  7. 
dropping  of,  in  extracting,  272. 
extraction   of.     See    Extraction 

of  Teeth, 
fractures  of,  in  extracting,  271. 
grasping  of,  for  extraction,  250. 
Hutchinsonian,     in     hereditary 

syphilis,   355. 
impacted,  extraction  of,  265. 
loosening  of,  for  extraction,  251. 
military     requirements     regard- 
ing, 403. 
misplaced,  extraction  of,  265. 
missing,    fractures    at    site    of, 

216. 
number  of,  72. 
parts  of,  cementum,  78. 
dentin,   77. 
enamel,  77. 
pulp,  78. 
permanent,   72. 
purpose  of,  74. 
situation  of,  77. 
sound  but  useless,  extraction  of, 

239. 
structural  parts  of,  77. 
supernumerary,     extraction     of, 

238. 
temporary,  72. 

unerupted,  mistaken  for  cancer, 
266. 
removal  of,  266. 


INDEX 


503 


Teeth,    wiring-    of,    for    reduction 
and  fixation  of  max- 
illary fractures,  235. 
Temporal   bones,  mastoid  portion 
of,  17. 
petrous  portion  of,  IS. 
squamous   portion   of,  17. 
Temporomaxillary  articulation,  39. 
Testis,  internal  secretion  of,  8S. 
Tetanus,  199. 

occurring     in     maxillary     frac- 
tures, 228. 
Therapeutic  fallacies.  126. 
Therapeutic    systems,   122. 
Therapeutics,   empirical,   120. 
and  materia  medica,  127. 
Nihilism  in,  12G. 
physical,   119. 
Therapies,  special,  122. 
Therapy,  schools  of,  120,  122. 
Christian    Science,    124. 
homeopathy,  122. 
osteopathy,  125. 
Thymus  gland,  relation  of,  to  de- 
velopment  of  sexual 
apparatus,  89. 
secretion  of,  or  colloid,  87. 
Tongue,  chief  artery  of,  70. 
1    clefts  of,  14. 

definition   and   anatomy  of,   69, 

76. 
development  of,  7. 
division   of,  69. 
muscles    of.       See    Muscles    of 

Tongue, 
nerves  of,  70. 
papillae  of,  70,  76. 
purpose  of,  74. 
Tonsillectomy,  361. 
Tonsillitis,      simulating      syphilis, 

359. 
Tonsils,  hypertrophied,  3G0. 
Tooth-anabolism,   relation   of  col- 
loid to,  87. 


Tooth   structure,   examination    of, 

239. 
Tracheotomy,   mortality    from,   in 

diphtheria,  390. 

Trichloracetic      acid,      destruction 

of      neoplasms      by, 

142. 
Trochoscope,  321. 
Tubercular       ulcers,       simulating 

syphilis,  358. 
Turbinates,  29. 
Typhoid   inoculation,   for  military 

service,  405. 

Fleers,  tubercular,  simulating 
syphilis,    358. 

Unerupted     teeth,     mistaken     for 
cancer,  266. 
removal  of,  266. 

Uniform,  for  military  service,  406. 

Utensils,  eating,  for  military  serv- 
ice, 408. 

Uvula  involvement  in  syphilis, 
353. 

Validol,  in  treatment  of  cocain 
poisoning,  148. 

Vasomotor  nerves,  recent  ad- 
vances in  study  of, 
96. 

Ventilation,    theories    in    relation 
to,  movement  of  air, 
95. 
the  skin,  94. 

Ventilation,  of  lungs,  aided  by 
skin,  94. 

Villi  of  small  intestine,  relation 
of,  to  adapted  nutri- 
tion of  nerve  cells, 
91. 

Vincent's     angina,     character    of, 
3S8. 
differentiated    from    diphtheria. 
389. 


504 


INDEX 


Vincent's  angina,  simulating  syph- 
ilis, 358. 

Visceral  arch,  H i  si ,  congenital  de- 
formities involving, 
14. 

Visceral  arches,  development  of, 
1. 

Vision,  required,  for  military 
service,    402. 

Vitamines,  and  beriberi,  90. 
definition   of,   91. 
popular  attention  given  to,  90. 

Vomer,  30. 

Vomiting,   post-operative,  157. 

Weight,  apothecaries',  136. 

determination  of  dosage  by,  129. 

required,    for    military    service, 
402. 
Weights  and  measures,  130. 


Wharton's   duct,   inflammation  of, 

369. 
Wick,  insertion  of,  in   a  fistulous 
tract,    technique    of, 
223. 
Witch  hazel,  142. 
Wormian  bones,  33. 
Wounds,  bandaging  of,  294. 
clean,  290. 
dressing  of,  294. 
gunshot,     and     roentgenology, 

335. 
hemorrhage  from,  291. 
septic,  291. 

suturing   of,    approximation   of 
parts,  291. 
types  of  stitch,  292. 

Zygomatic   injection   of  novocain, 
277. 


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